CHAPTER 1 CASE REPORT 1. Identification of Patients Name: Baby of Mrs. S Female gender Age / Date of Birth: 4 day / 23 October 2015 Address: Perbalan Semarang Sign RSDK: 24 October 2015 No. CM: C556501 Ward: NICU Mother's Name : Mrs. S Age: 40th Education: elementary school Occupation: self-employed Father's Name: Mr. P Age: 42th Education: elementary school Occupation: self-employed 2. Basic Data 2.1 History Alloanamnesis with the father and mother of the patient and medical record on October 28th 2015, at 12.00 pm in room NICU Main complaints: Referral newborns with severe asphyxia History of present illness On 23 October 2015 at 20.30 born baby girl from Mother P3A0, 38 weeks pregnant, 40 years, ANC (+) in Sp.OG, antenatal bleeding (-), Mother had a hystory of gestational disease, Hipertension (+), DM (+), consumption outside of prescription 2
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CHAPTER 1
CASE REPORT
1. Identification of Patients
Name: Baby of Mrs. S
Female gender
Age / Date of Birth: 4 day / 23 October 2015
Address: Perbalan Semarang
Sign RSDK: 24 October 2015
No. CM: C556501
Ward: NICU
Mother's Name: Mrs. S
Age: 40th
Education: elementary school
Occupation: self-employed
Father's Name: Mr. P
Age: 42th
Education: elementary school
Occupation: self-employed
2. Basic Data
2.1 History
Alloanamnesis with the father and mother of the patient and medical record on
October 28th 2015, at 12.00 pm in room NICU
Main complaints: Referral newborns with severe asphyxia
History of present illness
On 23 October 2015 at 20.30 born baby girl from Mother P3A0, 38 weeks pregnant,
40 years, ANC (+) in Sp.OG, antenatal bleeding (-), Mother had a hystory of gestational
disease, Hipertension (+), DM (+), consumption outside of prescription drugs (-), a history of
herbal drink (-), a history of abortion (-), a baby girl born in SCTP in RS Tugu on
indications severe preeclampsia, fetal distress, and polyhidramnion, at birth the baby didn’t
immediately cry, APGAR Score 1-2-3, BBL 3500 gram, ASI (+), manual delivery of the
placenta 15 minutes after delivery, complete cotyledons, no infarct, no hematom. History
injection of vitamin K (+), the baby was referred to RSDK for reasons of infant severe
asphyxia. when the baby arrived in the ER RSDK, the baby experienced apnea, looked bluish,
and HR was 68x/minute then performed intubation and CPR, after CPR the baby breathe
spontaneously. and HR increased by more than 100x / min, the baby have experienced shock
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given 0.9% NaCl bolus of 20 cc / kg and drip bobutamin 5 mcg / kg / min. Patients
programmed to do babygram, routine blood test, blood sugar when, urea, creatinine, sodium,
potassium, calcium and blood gas analysis. Attach the pipe orogastrik then flowed, then the
patient was transferred to the NICU, the patient is placed in an incubator and installed
monitors and ventilators with RR 25 mode, PEEP 5, PIP 15, FiO 2 of 60%. Patient's general
condition is still less active, looking limp and not crying. Ampicillin injection of 175 mg/12 h,
intravenous injection of gentamycin 20mg/24 jam , intravenous drip of dopamine 5 mcg / kg /
min.
2.2 Family History
- No family members or people in the neighborhood around the house sick like this
- No member of the family with a history of congenital heart disease, shortness of birth, blue
birth
- No member of the family with a history of birth defects
2.3. Socioeconomic history
Father and mother worked as a self-employed (the shop owner). Earnings per month
on average Rp 2.000.000,00. The cost of treatment by using non PBI BPJS.
Impression: lack of socioeconomic
3. Special Data
3.1 History of prenatal, natal, postnatal:
Prenatal: Mother G3P2A0 38 weeks pregnant, antenatal care regular 7 times in
doctor, immunization TT 2 times. A history of vaginal discharge during pregnancy denied, a
history of fever during pregnancy denied, denied a history of bleeding during pregnancy,
denied a history of trauma, history of herbal drink, drugs, and alcohol is undeniable.
Natal: Birth mothers 38 weeks pregnant P3A0, born SCTP helped SpOG on
indications severe preeclampsia, fetal distress, and polyhidramnion,500 grams birth weight,
body length 50 cm, birth indirect cry, jaundice (-).
Postnatal: After birth 1 day ago referred to RSDK because of severe asfixia
3.2 History of Eating and Drinking
Age 0 days giving breast milk diet was delayed due to severe asphyxia.
1 days given breast milk through a pipe orogastrik., dieting ASI 8 x 10-15 ml.
3.3 Basic immunization history and repeatedly
Hepatitis B : not done
Polio : not done
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BCG : not done
Impression: basic immunization has not been done.
3.5 History of Family Planning parents
Mother patients not using birth control.
4. Physical Examination (October 27, 2015)
Held on 27 october 2015 at 14:00 pm
Baby girl aged 27 days, weight 3500 grams, length50 cm.
General state: apatis, less active,spontaneous breathe
Vital signs
Blood pressure: 68/34mmHg MAP(46)
Heart rate : 107 times per minute
Breathing: 40 times per minute
Temperature: 36,2oC(axillary)
SpO2= 90%
Status internus:
• Head: Normosefali, head circumference = 32 cm, the large fontanelle = not closed, not
tensed, not obtrusived, caput succedaneum (-), cephal hematoma (-), black hair
evenly distributed, are not easily removed, scalp no abnormalities.
• Eyes: Round pupils, isokor, light reflex direct and indirect (+ / +)
• Nose: Normal form, the nostril breath (+ / +), secretions (- / -), septal deviation (-).
• Ear: Normotia, secretions (- / -), back quickly after being folded.
• Mouth : ET is attached, Cyanosis (-), trismus (-), labiopalatognatoschizis (-)
• Thorax
Lung :
• Inspection: hemithoraks dextra and the left symmetrically on
a state of inspiration and expiration, epigastric retraction (-)