Morning Report

Saturday, Feb 15th 2020

WWA/LZA/DEP/SRI/RAA
NO NAME GENDER DIAGNOSIS
1 Baby ANS Boy, 1. Respiratory distress ec TGA - VSD
4 days old Subaortic + ASD sekundum besar +
PDA
2. Suspect sepsis
3. Neonates full term – appropriate for
gestational age
1
New Patient of Perinatology admitted at 19.30 p.m , baby ANS, Boy, 4 days, address:
Dusun alue teuang
BW: 2.700 gr BL : 45 cm HC : 32 cm

Chief complain : Shortness of breath

- It was experienced since 6 hour after birth, cianotic found in the of the lips, hands
and nails of the hands and feet.
- shortness of breath has been found since 6 hour ago and does not decrease with rest.
- Fever, nausea and vomit was not found.
- yellowish was not found.
- babies whimpering, suck weak, less active movements
- desaturation was found
Past Medical History
Patient was referred from pediatrician at Bina Kasih Hospital with diagnosis cyanotic CHD ec
TGA - VSD + ASD big sekundum + Neonates full term – appropriate for gestational age

Medication History
- Inj. Cefotaxime 150 mg/ 12 hour ,inj gentamicin 125 mg/ 36 hour, inj furosemide 3 mg/ 12
hour,
- Spironolactone 1 x 2 mg, Captopril 3 x 1 mg
-Previous patients had echocardiography with TGA and ASD results
Pregnancy History
he patient is the fourth child. Mother's age when pregnant 31 years. ANC routinely goes to
obgyn and has no history of diabetes mellitus, hypertension or other diseases.
Birth History
he patient is born full term, born SC on indication of latitude. born spontaneously cried, bluish
was found, APGAR score was unknown,birth weight 2.900 gram and lenght 45 centimeter.
Physical Examination
General status :
BW : 2.700 gram BH : 45 cm,
(P > 2 SD)

Alertness : Compos Mentis Temperature :36,6°C

dyspnea (+), cyanosis (+), edema (-), icteric (-), anemia (+)

Localized status:
Head : Frontanel open flat, HC = 32 (Normo cephaly)
Face : Pale was found
Eye : Light reflexes (+/+), equal pupil Ø 3mm/3mm,
pale inferior palpebral conjunctiva (+/+)
Nose : Nasal Canul was found, 0,1 Lpm,
Mouth : Cyanosis was found, OGT clear impression,
Thorax : Symmetrical fusiform, minimal intercostal retraction
Heart rate : 158 beats/minute, regular, murmur (+)
Respiratory rate : 77 times/minute, regular, Whezzing (-/-) Ronkhi (-/-), O2
saturation 84-88%

Abdomen : Soft, normal peristaltic sound, palpable heart 3 cm below Arcus costa dextra

Extremities : pulse 158 beats/minute, regular, warm extremities, CRT < 2 second,
Perifer = central, Saturation 02 87 89
90 91
Down Score
breath frequency 1

Retraction 2

Cyanotic 2

Air entry 0

whimpering 1

Total 6
Laboratory result RSUP HAM 15/2/2020

•Hemoglobin : 9,9 g/dL

• Blood Glucose ad random : 172 mg/dL
•Hematocrit : 30 %
•Leukocytes : 22.000 /µL
• Ca ion : 6,90 mg/dL
•Platelets : 242.000 /µL
• Na : 141 mEq/L
•MCV : 105 fl
• K : 6,2 mEq/L
•MCH : 34,7 pg
• Cl : 107 mEq/L
•MCHC : 33,0 g/dl

E 0,20/B 0,30/N 79,20/L 10,60/M 9,70

Laboratory result RSUP HAM 15/2/2020

Arterial Blood Gas Analysis

•pH : 7,210
•pCO2 : 44 mmHg
•pO2 : 113 mmHg
•HCO3 : 17,6 U/L
•TCO2 : 19 U/L
•BE : -9,6 U/L
•SaO2 : 97%
Chest Xray 15/2/2020
overview of cardiomegaly
Working Diagnosis
1. Respiratory distress ec TGA - VSD + ASD big sekundum + PDA
2. Suspect sepsis
3. Neonates full term – appropriate for gestational age
Therapy
- Keep the baby in incubator with target skin temp 36,5-37,5 C
- intubation
- Daily fluid req : 150cc/kgBW/day
- Parenteral 150cc/kgBW/day
- IVFD D5%NaCl0,225%(430) + D40%(70) + KCL 10mEq + Ca gluconas 10cc  5 cc/hour
- Enteral : 100cc/kgBW/day
- Breast milk 5 cc/2hour/OGT
- IV Ampisilin 70 mg/12hourly
- IV gentamisin 11 mg/24 hourly
- inj Furosemide 2 x 2 mg
- spironolactone 2 x 2 mg
Planning
- Correction Hyponatremia
- transfution PRC 30 cc
- Consult to Pediatric Cardiology Division
- Consult to Pediatric Infection and Tropical Disease Division
- Echocardiography
Time Sens HR RR Temp SaO2 Additional
(bpm) (tpm)
02.30 CM 148 55 36,0 92%

03.00 CM 146 50 36,5 93%

04.00 CM 144 46 36,5 94%

05.00 CM 142 46 36,9 94%

06.00 CM 144 44 36,6 93%

07.00 CM 142 44 36,5 92%

08.00 CM 146 60 36,5 94%

Thank You