BEDSIDE TEACHING

Monday, April 12 2019

BY ALFADLI

ADVISOR DR. dr. H. Mustarim, Sp.A(K). M.Si. Med

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Patient Identity

• Name : By . N
• Date Of Birth : March/24/2019
• Age : 3 days on March 27/2019
• Gender : Male
• Religion : Islam
• Hospitalized : March 25 2019
• Main Complain
Breathless

• Additional complain
Feeding problem
 History Taking
• Baby through parents and nurse
The baby admitted in the NICU at 01.00 from Emergency unit, baby was born at
MMC Hospital by spontaneous delivery and help by Nurse APGAR Score was Below
7(4-5) and already given VIT K inj and Hep B Vaccine at that time soon after delivery
on March 24/2019 , after couple hours delivery the baby got breathing problem
breathlesnesess and need to be treated intensively also because the baby was
prematurely and baby body weigh just 900 gram
• Mother
Mother age was 25 years old, the gestational age was 34-35 Weeks g1p1a0 and
while on pregnancy the mother not routinely get her medical check up only
sometime went to health center. take medicine Folic acid Twice daily and no
remarkable complain during Pregnancy, such us eclamsia and pre-eclamsia,
discharge, and other

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 Family History

Unremarkable
Genetic Disease (-)

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 Physical Exam

Nutritional Status
Vital Sign
• Weight : 923 gram Height : 36 cm
Head circum : 22 cm,Abdomen circum
: 23cm

- Pulse : 142 Beat/minute

- Temp : 36,0 C - Length/Age : -3
- Respiration : 64/minute - Weight/Age : -3
- Spo2 : 93% - Ideal Weight : 2,5 - 3,5

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 Physical Exam
• Head : light reflex(+/+), Lips Cyanosis (-/-
),Sucking Refleks (-)
• Skin : Slighly Yellow (+) around the Abdomen
• Neck : Bull Neck (-),
• Thoraks : intercostal retraction (+), Grunting
sound (+), dyspnea (+)
• Pulmo : vesikular -/-, wh (-/-), rh –, Grounting
sound (+/+)
• Cor : Sound I/II regular, murmur -, gallop –
• Abdomen : Flexible(+), Bowel Sound (+) 8x/1
min
• Genitalia : Anus (+)
• Extremitas ; CRT <3 second, Warm Extramities
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 LABORATORY
• Labroratorium 25/3/2019
• CBC (RSUD Raden
Mataher) • 28/3/2019
• WBC : 7,43 10ˆ9/L (4- • BILLIRUBIN TOTAL : 14,2
10) • BILLIRUBIN DIRECT : 2,0
• RBC : 4,3 10ˆ9/L (3,5-5,5) • BILIRUBIN INDIRECT : 12,0
• HGB : 18,9 g/dl (11-16)
• HCT : 55,5 %(35-50)
• PLT : 130 10ˆ9/L (100-
300)

• Random Glucose : 65
mg/dl

• CRP : (-)
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Diagnosis

PREMATURE+RDS+NEONATUS VERY LOW BIRTH WEIGHT

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 TREATMENT
INCUBATOR
PHOTOTHERAPY 400-498 Nanomicro
OGT
CPAP f1o2 40 % Peep 6 Flow 7
IVFD D 10% + CALLCIUM GLUCONAS 2,6 mg/ hours
INJ AMPICILIN 2X50 MG/12 Hours
INJ GENTAMYCIN 5 MG/36 Hours
IV AMINOPHYLLINE 2X3 MG, MAINTENANCE 1,5/KG/EVERY DOSSAGE 8
HOURS
DIET 6X3 CC/OGT 4 HOURS
FLUID MAINTENANCE : 60 ml/kgbw as day 1
70 ml/kgbw as day 2 and so on

Education and inform concern to parents about the baby condition

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• ADVICE :
• X ray of the Thorax
• Routinely Cek the CBC and Billirubin, cek for Blood
Gas Analysis, Blood Culture, Place the ECG

• AND prevent collapse of the lung with SULFACTANT

• Continue the antibiotic as the culture result
THANKS