LAPORAN JAGA

2 JANUARI 2018

LOGO Reinardo Dafon P

22010116220312

Reviewer:
dr. Dimas Tri Anantyo, SpA
Mentor:
dr. Bob Kevin & dr. Sholikhin
ANAK 6 TAHUN DENGAN FEBRIS 5 HARI
DAN DIARE AKUT TANPA TANDA
DEHIDRASI

LOGO Reinardo Dafon P

22010116220312

Reviewer:
dr. Dimas Tri Anantyo, SpA
Mentor:
dr. Sholikhin
 IDENTITY OF PATIENT
 Name : An. MV
 Age : 6 yo (Dec 10th 2011)
 Gender : Male
 Adress : North Semarang
 No. MR : C317101
 Room : C1L1
 Charged date : Dec 30th 2017

 Mother’s Name: Mrs. L  Father’s Name: Mr. DM

 Age : 34 years  Age : 41 years
 Occupation : House wife  Occupation : Labor
 Education : SD  Education : SD
BASIC INFORMATION
 Anamnesis:
Alloanamnesis with patient’s mother and father on Dec 30th
2017 at 20.00 PM
 Present Medical History
Chief Complain: newborn neonates
 On May 21st 2017 at 07.09 PM a baby boy was born
with section caesarean with indication of premature
rupture of the membrane (PROM) ± 7 days from a 25 y.o
mother with G1P0A0 34 weeks of gestation
 No history of nausea, vomiting, extremity oedema, nor
hypertension, DM, cardiovascular disease, asthma, fever,
trauma, long period of coughing, shortness breathing,
ANB, PROM (+) 1 week prior to delivery.
BASIC INFORMATION
 ANC was done 4 times in SpOG, at 3, 5, 7, and 8 months
pregnancy by obstetricians. Mother did TT immunization
2x, she also consumed Fe and vitamins, comsumption of
drugs and herbs denied.
 A mother came to the RSDK on May 14th 2017 at 06.00
AM with indication PROM since ± 11 hours ago. No
history of trauma, coitus, dysuria, fever, ANB, toothache.
She complained had a fluor albus since ± 2 weeks ago
and achieved drugs from obstetricians.
 A mother received corticosteroid injection for lung maturity
of the fetus, tocolitic to maintain the pregnancy, and
antibiotic prophylaxis to prevent chorioamnionitis. Drugs
for lung maturity finished given on May 16th 2017 at
01.00 AM
BASIC INFORMATION
PEDIGREE FAMILY HISTORY
There is no family
member with a
history of similar
complaint
There is no family
member with a
history of premature
baby
BASIC INFORMATION
PSYCHOSOCIAL- SOCIO-ECONOMIC
ECONOMY HISTORY CRITERIA BY BPS
 Father and mother is  Total score: 15
working as employee  BPS criteria: Total Score
with income ± < 10 = poor; ≥ 10 =
5.000.000 per month not poor
 Bear 1 children who are  This family is
not yet independent categorized as a not
 Cost of treatment with poor family
“BPJS”
SPESIFIC INFORMATION
PERINATAL HISTORY
Prenatal  Natal
ANC was done 4x, at 3, 5, Female, G1P0A0, 25
7 and 8 months pregnancy years old mother, 34
(by obstetricians). Mother weeks GA, SC delivery,
did TT immunization and cry spontaneously, BBW:
consumed Fe and 2620 gram, BBL: 47 cm,
vitamines. Consumption of HC: 34 cm, CC: 32 cm,
drugs and herbs denied. icterus(-), cyanosis (-),
Hypertension(-), DM(-), PROM (+) ± 7 days
fever (-), trauma(-).
SPESIFIC INFORMATION
PERINATAL HISTORY
Postnatal
Apgar Score: 8 – 9 – 10
10 minutes after delivery, the baby got retraction
(+), grunting (+) and flaring nostrils (+). The baby
was given O2 CPAP PEEP 5 flow 6 lpm FiO2 30%.
After the baby stabilized, he got O2 nasal canule
0,5 lpm and infusion D10% 168/7mL/hour
through umbilical cord and went to the PBRT Dr.
Kariadi General Hospital.
 SPESIFIC INFORMATION
Immunization
Primary immunization has not been given

Food and Drink History

Jenis Pemberian Cairan Kalori Protein Lemak
120ml/kg 110kkal/kg 1g/kg 1g/kg
Kebutuhan 24 jam 312 286 2,6 2,6

D10% 240 81,6 - -

Aminosteril 87 20,6 5,2 -
Ivelip 26 46,4 - 5,2
ASI 160 108,8 1,68 6,24
Total 513 257,4 6,88 11,44
AKG % 164,4% 90% 264,6% 440%
SPESIFIC INFORMATION
GROWTH AND DEVELOPMENTAL
Cross sectional
 Birth weight : 2620 gr
 Birth length : 47 cm
 HC : 34 cm
 CC : 32 cm
Lubchenko Curve
 Preterm, appropriate
for gestational age
 SPESIFIC INFORMATION
GROWTH AND DEVELOPMENTAL
Cross sectional
 Birth weight : 2620 gr
 Birth length : 47 cm
 HC : 34 cm
 CC : 32 cm
Fenton Growth Chart
 BBW: between percentil 50 and 90
 BBL: betwen percentil 50 and 90
 HC: between percentil 90 and 97
SPESIFIC INFORMATION
Contraception History
Mother is not taking any contraception device now
 PHYSICAL EXAMINATION (May 24 )
th
General Condition :
Compos mentis, awake, active.
Vital Sign
HR : 138 x/min t = 36,5oC
RR : 40 x/min
Status Internus
 Head : head circumsference: 34 cm  mesocephal, flat
fontanelle, not yet closed, caput succadenum (-),
cephalhematoma (-)
 Face : dismorphic (-)
 Eyes : conjunctiva anemis (-/-), icteric sclera (-/-),
secretions (-/-)
PHYSICAL EXAMINATION (May 24 )
th
 Nose : flat nasal bridge (-) flaring nostrils (-/-),
discharge (-/-)
 Ear : discharge (-/-), cartillage not yet fully
formed (+/+)
 Mouth : cyanosis (-), labiognatopalatoschizis (-),
macroglossy (-)
 Neck : symmetrical, enlarged lymph nodes (-),
webbed neck (-)
PHYSICAL EXAMINATION (May 24 )
th

THORAX
Lung
Inspection : symmetrical at static and dynamic
condition, retraction (-)
Palpation : can’t be assesed
Percussion : can’t be assesed
Auscultation : vesicular +/+ normal, ronchi -/-,
wheezing -/-,
PHYSICAL EXAMINATION (May 24 )
th

THORAX
Heart
Inspection : ictus cordis is not inspected
Palpation : ictus cordis located on ICS IV, 2cm
medial of midclavicular sinistra line
Percussion : can’t be assesed
Auscultation : heart sound I-II normal, murmur (-),
gallop (-)
PHYSICAL EXAMINATION (May 24 )
th

ABDOMEN
Inspection : flat, venectation (-)
Auscultation : sound of bowel (+) normal
Palpation : supple, normal turgor, hepar and spleen
are not palpable
Percussion : spreading tymphani at all abdomen
regio
PHYSICAL EXAMINATION (May 24 )
th
 Lymph node : no enlargement
 Genitals : male, OUE (+), testis +/+
 Anus : (+), hyperemia(-)

 Extremities Superior Inferior

 Oedem -/- -/-
 Cyanosis -/- -/-
 Warm ext +/+ +/+
 CRT <2” <2”
 Fingers complete complete
 Creases 2/3 anterior 2/3 anterior
PHYSICAL EXAMINATION (May 24 )
th
 Primitive Reflexes:
 Rooting reflex : (+)  Abdominal reflex: (+)
 Sucking reflex : (+)  Cremaster reflex : (+)
 Snouting reflex : (+)  Anal reflex : (+)
 Palmomental reflex : (+)  Babinski reflex : (+)
 Glabella reflex : (+)  Moro reflex : (+)
 Palmar grasp reflex : (+)
 Plantar grasp reflex: (+)
 PHYSICAL EXAMINATION (May 24 )
th
Downes Score
Criteria 0 1 2

Respiratory Rate <60x/min 60-80x/min >80x/min

Retraction No retraction Mild retraction Severe retraction

Cyanosis No cyanosis Cyanosis relieved by O2 Cyanosis on O2

Air entry Good bilateral Mild decrease in air entry No air entry
air entry
Grunting No grunting Audible by stethoscope Audible with ear

 Scoring:
 1-3 : Mild respiratory distress
 4-7 : Moderate respiratory distress
 >7 : Severe respiratory distress
 0 : No respiratory distress
PHYSICAL EXAMINATION (May 24 )
th
New Ballard Score
 Appropriate for 30-32
weeks gestational age
FURTHER DIAGNOSTIC EXAMINATION
X-PHOTO BABY GRAM (MAY 21st 2017)
Interpretation:
• No enlargement of cor
• Pulmo shows image of
neonatal pneumonia
• Normal abdomen
FURTHER DIAGNOSTIC EXAMINATION
BLOOD EXAMINATION (May 21 2017)
st
Hematologi
Hematologi Paket
Pemeriksaan Hasil Satuan Nilai Rujukan Keterangan
Hemoglobin 16,2 g/dL 13,60 – 19,60
Hematokrit 49,7 % 44 – 62
Eritrosit 4,97 106/uL 3,1 – 5,1
MCH 33,8 pg 24,00 – 34,00
MCV 103,8 fL 83 – 110
MCHC 32,6 g/dL 29,00 – 36,00
Leukosit 13,9 103/uL 9 – 30
Trombosit 369 103/uL 150 – 400
RDW 15,8 % 11,60 – 14,80 High
MPV 9,2 fL 4,00 – 11,00
Kesan Increase of RDW
Hitung Jenis
Pemeriksaan Hasil Satuan Nilai Rujukan Keterangan
Eosinofil 6 % 2–4 High
Basofil 0 % 0–4
Batang 1 % 2–5 Low
Segmen 29 % 45 – 75 Low
Limfosit 45 % 20 – 40 High
Monosit 19 % 3 – 12 High
Lain-lain Eritrosit Berinti : 4/100 Lekosit
Kesan Eosinofilia
Neutropenia
Limfositosis
Monositosis
Kimia Klinik
Pemeriksaan Hasil Satuan Nilai Rujukan Keterangan

Gula darah sewaktu 47 mg/dL 80 – 160

Calcium 2,10 mmol/L 2,12 – 2,52 Low
Elektrolit
Natrium 136 mmol/L 136 – 145
Kalium 3,9 mmol/L 3,5 – 5,1
Chlorida 106 mmol/L 98 – 107
Kesan Hipokalsemia
FURTHER DIAGNOSTIC EXAMINATION
OAE EXAMINATION (May 23rd 2017)
 Right Ear : Pass
 Left Ear : Pass
 Impression : Good for both ear at sensory
hearing function
 Control : Evaluation for OAE 1 months later
PROBLEM LIST
No. Masalah Aktif Tanggal
No Masalah Aktif Tanggal

Preterm (34 weeks) with 6. Eosinophilia

1. 21/05/2017 21/05/2017
section caesarean
History of moderate 7. Neutropenia
2. respiratory distress, 21/05/2017 21/05/2017
Downes Scores 4
8. Lymphocytosis
Image of neonatal
3. 21/05/2017 21/05/2017
pneumonia (Ro)

9. Monocytosis
4. Increase of RDW 21/05/2017 21/05/2017

Nuclear erythrocyt 4/100 10. Hypocalcemia

5. 21/05/2017 21/05/2017
leukocytes
DIAGNOSIS
1. Neonatus preterm (34 weeks of gestation)
2. NBBW (2620 gram)
3. History of moderate respiratory distress
(Downes Scores 4)
 INITIAL PLAN
1. Neonatus preterm (34 weeks of gestation)
Ip Dx : S :-
 O :-
Ip Rx : baby care in incubator
Ip Mx : general appearance, vital signs, blood sugar
level, hypoglicemia sign, hypothermia and
hyperthermia sign
Ip Ex :
• Explain to parents about the condition of preterm
baby and treatments given
• Explain to parents about complications which may
occur to the premature baby
• Explain to parents to keep the baby warm, if the
baby is in stable conditions teach mother how to do
kangaroo mother care
 INITIAL PLAN
2. History of Moderate Respiratory Distress
Ip Dx : S :-
 O : complete blood count (CBC), blood gas
analysis (BGA), electrolyte
Ip Rx : O2 nasal cannule 0,5 liter/min
Ip Mx : general appearance, vital signs, FiO2,
respiratory distress sign
Ip Ex :
• Explain to parents that the baby had a tachypnea
and need an oxygen therapy to supply baby’s oxygen
to the tissue
• Explain to parents about respiratory distress signs
such as tachypnea, retraction, flaring nostrils, grunting,
cyanosis. And if the parents find one of that signs,
control to the doctor.