Interesting Case

th
March, 15 2016
Sri Yati, Charles, Aulia, Fanny,
Sasa

PATIENT IDENTITY
Name

: Mr. B. D. Baby
Age
: 1 hours
Sex
: Male
Address
: Klaten
Admission date : March, 15th 2016

Chief complaint:
Arrhythmia (referral case from Bagas Waras
Hospital)

History Taking
22 hours baby was born from P1A0, 40 weeks gestasional of

age, spontaneous delivery. AS 6/7, resuscitation until initial

step. Birth weight 2730 gram height 48 cm, head
circumference 31,5 cm
In previous hospital, baby only got oxygenation 2 lpm canul
nasal, spO2?,
No cyanotic -> referral RSS

Antenatal History
No complaints during pregnancy, weight gain during

pregnancy ?kg. Routinely control to midwife and doctor, got

supplementation for pregnancy.
Pregnancy USG (2 nd trimester) -> Arytmia
Check TORCH
IgG anti Rubella : +
IgM anti Rubella :IgG anti CMV : +
IgM anti CMV : Got Asiklovir therapy twice/day (until 2 weeks)

Physical Examination
O: Crying, active movement

Thermoregulation : 36.5 C
CNS : S5, no lethargy, no seizures
CVS : HR: 140-150x/minute
warm acral, strong pulse, CRT < 2 second
single S1, S2 splitted unconstantly, no murmur, arrhythmia

Respiratory: RR: 40 -50 x/minute, no grunting, no chest

retraction, no cyanosis, SpO2 : 98 % Downes score : 0

 GIT : Defecation (+), peristaltic (+)

Hepar : not palpable

Lien: not palpable
GUT : Spontaneously micturition (+)
Integ and extremities : no pale, no icteric, no cyanotic, no
purpura

Laboratory Finding (15-3-2016)

Examination

Value

Referal value

Hemoglobin (g/dL)

18.2

11-15

Hematokrit (%)

53.1

32 - 47

130.000

150 440 000

Leukosit (uL)

12.550

3.6 11 000

-Neutrofil (%)

69

50 70

-Limfosit (%)

21.8

20 - 40

-Monosit (%)

7.1

28

-Eosinofil (%)

1.5

13

- Basofil (%)

0.6

0-1

MCV (fL)

103.7

80 - 100

MCH (pg)

35.5

27 - 32

MCHC (g/dL)

34.3

32 - 36

Trombosit

RDW (%)

11.5 14.5

Laboratory Finding (30-3-2015)

Examination

Value

Referal value

Total bilirubin

5.94

< 8.7

Direct bilirubin

0.66

< 0.6

Albumin

3.51

3.5-5.5

Blood glucosa

36

74-110

Natrium

136

136-145

Kalium

4.5

3,5- 5,1

Clorida

104

98-107

Calcium

2.14

2,1-2,5

Blood Gas Analysis (March 15th 2015)

Result

Reference

pH

7.321

7.350-7.450

pCO2

41.4

35.0-45.0

HCO3

20.9

22.0-26.0

pO2

47.3

>80.0

BE

-4.9

-2.0-2.0

AaDO2

52.8

SO2

78.3

Data List
Male, 2 days old
HR: 200-210 bpm
No mur-mur

Arrhythmia
ECG : Total AV block
no hepatomegaly
Normal JVP
No edema
No tachypnea
Conclusion : Functional Dx : no heart failure, Etiological Dx : asianotic CHD,

Anatomical Dx : susp ASD

Data List

Male
40th week of Gestational age
Appropriate for gestational age
Spontaneous delivery from G2P1A0 (first child was terminated at 30 th week of
gestational age due to hydrocephalus and down syndrome)

Conclusion :
Normal birth weight,aterm, appropriate for gestasional age, spontaneous delivery

Data list
Head circumference 31.5 cm (below -2SD)

Conclusion : Microcephal

Working Diagnosis
Arrhythmia ec congenital av block
Normal birth weight,aterm, appropriate for gestasional age,
spontaneous delivery
Mikrosefali

Integrated planning
No Problems
.
1. Arrhythmia
2.

Patients need

Planning & goals

Etiologic finding

ECG
Echocardiography
Thermoregulation
Umbilical cord care
Fluid requirement

Normal birth Neonatal care

weight,aterm
, appropriate
for
gestasional
age,
spontaneous
delivery

Integrated planning
No Problems
.
3.

Microcephal

Patients need

Planning & goals

Etiological finding Head ultrasonography

Congenital Rubella Syndrome

(CRS)
Birth defects if acquired by a pregnant woman: deafness,
cataracts, heart defects, mental retardation, and liver
and spleen damage (at least a 20% chance of damage
to the foetus if a woman is infected early in pregnancy), (
16-18% if maternal infection was acquired between 1320 weeks of gestation, according to The Lancet).
After 20 weeks the incidence is less than 2% (Landelijke
Infectieprotocollen Ndl.). No defects after 16 weeks
according (The Lancet, 1982).
The foetus produces IgM and IgG. IgM in the newborn is
evidence of CRS. Differentiation of the IgG is difficult.
After 1 month maternal IgG is more or less cleared.
http://www.cdc.gov/nip/ed/slides/rubella8p.ppt#314,1,Dia 1
Miller E, Cradock-Watson JE, Pollock Tm. Consequences of confirmed maternal rubella at successive stages of pregnancy.
Lancet 1982; 2: 781-784.