CASE CONFERENCE

MONDAY, APRIL 24TH 2017

dr. Iqbal / dr. Devi

dr. Aya / dr. Ifa / dr. Rekno / dr. Mono
dr. Eddy / dr. Rini
1
dr. Pitra / dr. Cempaka / dr. David
 PATIENT ADMISSION
2

MELATI 2 WARD : -
HCU NEONATUS:
Baby Ms.S, babyboy, 0 day, 2900 grams, mild hypothermia, mild asphyxia,
neonate normo birth weight, aterm, appropiate for gestational age, sectio
caesaria delivery due to impendig eclampsia
Baby Ms.K, baby girl, 0 day, 3600 grams, mild hypothermia neonate normo birth
weight, post term, appropiate for gestational age, sectio caesaria due to
oligohydramnion
Baby Mrs.S, baby girl, 0 day, 700 grams, severe asphyxia e.c Hyalin
Membrane Disease dd/ Congenital pneumonia, suspect Hyalin
Membrane Disease dd/ Congenital Pneumonia, neonatal sepsis, neonate
extremely very low birth weight, preterm, appropiate for gestational
age, vaginal delivery with premature rupture of membrane (4 days)
Baby Ms. R, baby boy, 0 day, 3200 grams, caput succedaneum dd cephal
hematoma, mild hypothermia, neonate normo birth weight, aterm, appropiate
for gestational age, post vacum extraction due to prolonged labour
PICU : -
HCU MELATI 2 : -
3 PATIENT IDENTITY

NAME : Baby Mrs. S

SEX : female
AGE : 0 days
BODY WEIGHT / HEIGHT : 700 grams / 32 cm
ADDRESS : Gatak, Sukoharjo
MEDICAL RECORD : 01377044
ADMISSION : April, 24th 2017
4 CHIEF COMPLAIN

Premature Newborn
 CURRENT MEDICAL
5 HISTORY
- the mother had uterus contraction irregularly.
- She also felt discharge outside from her vagina, no bloody
discharge or mucous start from 4 day ago
- She still feel the movement of her baby inside
- No fever, no hypertension
Then she went to Moewardi hospital

The baby was born from 40 years old mother,

G2P1A0, 25 weeks gestational age, vaginal delivery
due to Premature Rupture of the Membrane
(PROM). Shortly after birth, the baby cried not
vigorously, inactive movement, looked cyanotic with
Apgar Score was1-2-3
 History pregnancy and
6 labor PREGNANCY
Her mother 40 years old, this was her second pregnancy,
gestational age was 25 weeks, antenatal care was routine in
midwife every month, mother denied any kind of illness
during her pregnancy, never been hospitalized. She had done
4 times ultrasonography during her pregnancies in
Obstetrician, the obstetrician tell her that her preganancy
was quite fine.

LABOR
Patient was born by vaginal delivery indicated for premature
rupture of the membrane (4 days), baby girl, 700 grams
weight, 32 centimeters length, did not cry vigorously,
showed less active movement, spontaneously opened her
eyes, cyanotic episode reported.

CONCLUSION : pregnancy and labor was abnormal

7 HISTORY OF IMUNISATION

Patient has not got imunisation yet

 8 PEDEGREE

I
I

III

Baby of Mrs. S, 0 Day

9 Nutritional status
BW/U : 700/800 X100% = =
P10<BW/U<P50
BH/U : 32/33 X 100% = = P10<BH/U<P50
BW/BH : 700/700 X 100% = =
P50<BW/BH<P90

Conclusion :
wellnourished, normoweight, normoheight

Ballard score 5 appropriate with 25 of

gestational age
 PHYSICAL EXAMINATION
Issues Respiratory distress
11
CNS cry vigorously(-), Head Circumference = 27 centimeters
Active movements (-)
Spontaneously opened her eyes (+)
Assessment: S2

CV system Heart rate : 158 bpm

Murmur (-), capillary refill time < 2 , DPA strong palpable
Assessment: normal

Respiratio Respiration rate: 68 bpm

Chest retraction (+) subcostal, suprasternal, acrocyanotic (+)
n system Air entry (+) Grunting (+)
Downes score (6) on oxygen support
Assessment : severe respiratory distress

GIT Distended (-), umbilical hernia(-), bowel sound (+), vomitus (-), icterus (-)
Assessment : normal
system
Genitourinary Urine output can not be evaluated
system Assessment: can not be evaluated

State of Thermoregulation status GIT system (-) Assessment:

infection (370C ) Genitourinary Neonatal sepsis
CNS (+) S2 system(-)
CV system (-)
Respiration system : severe
respiratory distress
12 Localized status :
Pedis sinistra region
There is crustae with
black colour at plantar
pedis sinistra region
Bullae (+)content of
clear liquid, pus(-),
blood(-)
 LABORATORY EXAMINATION
13
(th 25th April 2017)
Hb : 15.2 g/dl Blood sugar : 62 mg/dl
HCT : 46 % Blood type : B
AL : 22.0 Rhesus : (+)
thousand/ul Albumin : 3.2 g/dl
AT : 195 thousand/ ul Sodium : 139 mmol/L
AE : 4.02 mil/ul Potassium : 4.5 mmol/L
MCV : 114 /um Chlorida : 112 mmol/L
MCH : 37.8 pg Calcium : 1.05 mmol/L
MCHC : 33.1 g/dl
Netrophyl : 56.5 % Conclusion :
Limphocyte : 31.4 % - Normal limit
Monocyte : 12.10 %
 PROBLEM LISTS
14

Baby Mrs. S, 0 day old with :

Extremely Very low birth weight
Cried not vigorously
Less active movement
Baby was born by vaginal delivery due to premature rupture
of the membrane (4 days) at 25 weeks gestation
Apgar score 1-2-3
Birth weight = 700 grams
CNS system : S2
Down score : 6, Retraction subcostal, supraepigastrial,
grunting, air entry (+), severe respiratory distress
Neonatal sepsis
15 DIFFERENTIAL DIAGNOSIS
1. Neonatal sepsis
2. Severe asphxia due to Hyalin membrane
disease dd congenital pneumonia
3. Susp. Hyalin membrane disease dd
congenital pneumonia
4. Traumatic bullae pedis sinistra due to
compression
5. Neonatus extremely very low birth
weight, premature, small for gestasional
age, vaginal delivery due to premature
rupture of the membran (4 days )
16 WORKING DIAGNOSIS
1. Neonatal sepsis
2. Severe asphxia due to Hyalin membrane
disease
3. Hyalin membrane disease
4. Traumatic bullae pedis sinistra due to
compression
5. Neonatus extremely very low birth weight,
premature, small for gestasional age, vaginal
delivery due to premature rupture of the
membran (4 days )
17 THERAPY
Admitted to NICU
Oxygen On ventilator (NIV) FiO2 40%, RR 40 bpm, PEEP
5cmH2O
Applied umblical catheher D5% 3.5 ml/hour
OGT evaluate gastric recidu, if no recidu priming with
breastmilk 8x 3- 5ml
Cefotaxime injection 50 mg / kgBW /x~ 35 mg/ 12 hours
Gentamycin injection 5 mg/ kgBW/24 hour ~ 3,5 mg/48
hours
Aminophyllin injection loading 7 mg then 3.5 mg/8 hours
Aminosteril 6% 2.5 gr/kgBW/day ~25 cc/24 hours ~ 1,2
cc/hour
Dobutamin injection 5 mg + NaCl 0.9% ~ 12 ml 0.5
cc/hour
 PLAN
18

1. Septic work up : DL2, blood

culture, GDT/IT ratio,
albumin,electrolyte, hsCRP

MONITORING

General appearance / vital sign/hours

fluid balance / diuresis / 8 hours
 FOLLOW UP 25TH APRIL
Issues
CNS
19 2017
Respiratory distress
cry vigorously(-), Head Circumference = 27 centimeters
Active movements (-)
Spontaneously opened her eyes (+)
Assessment: S2

CV system Heart rate : 158 bpm

Murmur (-), capillary refill time < 2 , DPA strong palpable
Assessment: normal

Respiratio Respiration rate: 68 bpm

Chest retraction (+) subcostal, suprasternal, cyanotic (-)
n system Air entry (+) Grunting (+)
Downes score (6) on oxygen support
Assessment : severe respiratory distress

GIT Distended (-), umbilical hernia(-), bowel sound (+), vomitus (-), icterus (-)
Assessment : normal
system
Genitourinary Urine output can not be evaluated
system Assessment: can not be evaluated

State of Thermoregulation status GIT system (-) Assessment:

infection (370C ) Genitourinary Neonatal sepsis
CNS (+) S2 system(-)
CV system (-)
Respiration system : severe
respiratory distress
20 WORKING DIAGNOSIS

1. Neonatal sepsis
2. Severe asphxia due to Hyalin membrane
disease
3. Susp. Hyalin membrane disease
4. Traumatic bullae pedis sinistra due to
compression
5. Neonatus extremely very low birth weight,
premature, small for gestasional age, vaginal
delivery due to premature rupture of the
membran (4 days )
21 THERAPY
Oxygen On ventilator (NIV) FiO2 40%, RR 40 bpm, PEEP
5cmH2O
Applied umblical catheher D5% 3.5 ml/hour
OGT evaluate gastric recidu, if no recidu priming with
breastmilk 8x 3- 5ml
Cefotaxime injection 50 mg / kgBW /x~ 35 mg/ 12 hours
Gentamycin injection 5 mg/ kgBW/24 hour ~ 3,5 mg/48
hours
Aminophyllin injection loading 7 mg then 3.5 mg/8 hours
Aminosteril 6% 2.5 gr/kgBW/day ~25 cc/24 hours ~ 1,2
cc/hour
Dobutamin injection 5 mg + NaCl 0.9% ~ 12 ml 0.5
cc/hour
Nacl 0.9% compress + gentamycin ointment for bullae at
 PLAN
22

1. Baby gram

MONITORING

General appearance / vital sign/hours

fluid balance / diuresis / 8 hours
When we give initial surfactant treatment in very
low birth weight?
P : Very low birth weight neonates

I : early initial treatment

C : intermediate and late initial treatment

O : prognosis
26
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