laporan kasus

1. CLINICAL CONFERENCE
NEONATOLOGY DIVISION
FEBRUARY 25th 2022
Zulyudisiawan Muin/ Presenter
Kartika Setiawaty/ Madya
Muh. Alief, Syahrurrahman, Kharisma Andi Akhmad / Senior

2. MR Number
Date of Birth
Admission Date
968340
February 10th 2022
February 22th 2022
RESPIRATORY DISTRESS OF THE NEWBORN ET CAUSA PNEUMONIA + ACYANOTIC CONGENITAL
HEART DISEASE ET CAUSA ATRIAL SEPTAL DEFECT + VENTRIKEL SEPTAL DEFECT + MULTIPLE
CONGENITAL ANOMALY + ATERM BABY / APPROPRIATE FOR GESTATIONAL AGE
By. Mrs AF (Female)
MEDICAL DIAGNOSIS

3. A Baby gIRL, 11 day old was referred from Andi makasau general
hospital with diagnosis of Congenital Anomaly (Atrial Septal Defect +
Ventrikel Septal Defect + Transient Tachypnea of the Newborn)
There was shortness of breath since birth accompanied by cyanosis. No
fever, no seizure, no cough, no vomiting.
The baby got breast milk via OGT
Defecation : Yellow normal
Urination : Normal, Yellow

4. Pregnancy history: 26 years old mother, Third pregnant, routine checkup at the Primary healt care
and Obstetrician, and routine take vitamins and blood boosters. There were no history of hypertension,
diabetes mellitus, allergies, heart disease, asthma, urinary tract infection or vaginal discharge that was
itchy and smelly.
Birth History : Babies born spontaneously,aterm baby, not crying immediately, weak muscle tone,
BW : 2.575 grams, BL: 46 cm, HC : 32 cm APGAR score: 6/7, Gestational age : 38 weeks
History of being hospitalized at Andi Makasau hospital since birth, got treatment oxygenation with
nasal canul, Ceftriaxone / intravenous (10 day), Amikasin / intravenous (10 day), and Furosemide (2
day)

5. Vital Sign
General Status: Passive
Heart Rate : 130 bpm
Temperature : 36.6 °C
Respiration Rate : 62 times/minute
SpO2 : 98% with low flow nasal canul
Pain Scale : 0 NIPS
Birth weight : 2575 gr
Body Weigth : 2535 gr
Birth length : 46 cm
Head circumference : 32,5 cm
Gestational age : 38 weeks

6. Birth weight : 2575 gr
Body length : 46 cm
Gestational age : 38
weeks

7. Head circumference :
32,5 cm
gestational age :
38 weeks

8. History of Vaccine
Vaccine
Frequency
Not given 0 1 2 3 4
Hep B v
BCG v
DPT v
Hib v
OPV v
IPV v
MMR v
Rotavirus v
Influenza v
Japanese
Encephalitis
v
PCV v
Varicella v
Hepatitis A v
Tifoid v

9. 9
Observe the hand : not yet
Grabbing object : not yet
Prone position by self : not yet
One syllables : not yet
Pointing the object : not yet
First tooth : not yet
History of Growth
and
Development

10. Head And Neck
Normocephal
No lymphadenopathy
Chest and pulmo
There was minimal subcostal retraction
Breath sounds brochovesicular
There was no ronchi
There was no wheezing
Down Score (2) :
Breathing Frequency : 1, retraction 1,
Cyanosis 0, Air entry 0, Groan 0
Cardiovascular
I / II heart sound, Regular rhythm
There was murmur ejection systolic
Warm akral, CRT < 3 Second
Gastrointestinal
Peristaltic sound normal
Liver and spleen were not palpable
Metabolic
No oedem, no jaundice
Urination: yellow
Hematology
No paleness, no bleeding
Others :
- Dysmorphic face
- Dysplastic ear
- Hypertelorisme
- Tongue tie
- Wide space nipple
- Simian line
- Widely spaced big toes
- Rocker bottom foot

11. Wide space nipple
Dysmorphic face
Hypertelorisme
Dysplastic ear
Tongue tie
Simian line
Widely spaced big toes
Rocker bottom foot

12. LABORATORY EXAMINATION
Laboratory
February
23th 2022
(Wahidin)
Normal Value
Hb 18,9 12.0 – 16.0 gr/dL
WBC 9.010 4.0 – 10.0/μL
PLT 302.000 150.000 – 400.000/mm3
MCV 102,2 80 -100 μm3
MCH 34,2 27 - 32 Pg
NEUT 49 52 – 75 103/μL
LYMPH 38,6 20 – 40 103/μL
MONO 9,9 2 – 8 103/μL
GDS 104 <140 mg/dl
Albumin 3,6 3.5 – 5.0 mg/dl
AST 72 <38
ALT 23 <41
Natrium 131 135-145
Kalium 4,0 3,5-5,1
Clorida 100 97-111
Ureum 27 10-50 mg/dl
Creatinin 0,31 <1,3 mg/dl

13. Radiologycal Finding
Thorax X-Ray 23/2/2022
Impression :
- Pneumonia Dextra

14. ECHOCARDIOGRAPHY
Andi Makasau Hospital
15/2/2022 :
- Atrial Septal Defect +
Ventrikel Septal Defect
- Dilatation of RA, RV

15. • RESPIRATORY DISTRESS OF THE NEWBORN ET CAUSA
PNEUMONIA
• ACYANOTIC CONGENITAL HEART DISEASE ET CAUSA
ATRIAL SEPTAL DEFECT + VENTRIKEL SEPTAL DEFECT
• MULTIPLE CONGENITAL ANOMALY
• ATERM BABY + APPROPRIATE FOR GESTATIONAL AGE

16. Incubator
Oxygen 0,5 Lpm via low flow nasal canul
Fluid Requiremens (Formula Milk) : 150ml/kgBW (+ 20% Incubator) - (20% Respiratory
Distress) = 375 ml/24 hours
Enteral :8 X 50 cc ( Breast Milk )
Parenteral : Infuse Dextrose 10% 15,6 cc/hour
Planning
- Consult to Cardiology

17. THANK YOU