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CHAPTER 3
CASE REPORT
History taking
:
Chief complaint
: Shortness of breath
A male newborn, named DNM, was admitted to the neonatal unit at General Hospital
Haji Adam Malik Medan (RSUP HAM) on June 9, 2015 with shortness of breath as
the chief complaint. The neonate was born on the same day, about one hour before
admission to the hospital with gestational age = 30-32 weeks. This complaint had
been experienced since delivery with no history of bluishness. When admitted, the
newborn had weak cry, less of activity, and weak suckle. Urinate (+) normal.
Meconium hadnt been yet excreted.
History of pregnancy : the neonate is the first baby born to the 20-year-old mother.
History of diabetes (-), gestational diabetes (-), hypertension (-), fever during
pregnancy (-), PROM (-). History of mother with fever (-), herb & medication use
(-).
History of delivery
helped by a midwife and immediately crying. Birth weight (BW) = 1860 gr, birth
length (BL) = 37 cm, birth head circumference = 29 cm. APGAR score was unclear.
Vitamin K injection was unclear.
Physical examination
:
Sensorium
: compos mentis
Temperature : 36.5C
present BW : 1860 gr
present BL
: 37 cm
Anemia (-)
Jaundice (-) Cyanosis (-) Dyspnea (+) Edema (-)
Downe Score = 6
CNS system
: stable
Head : anterior fontanelle is still palpable. Head circumference = 29 cm.
Eye : light reflex (+) normal, isochoric pupils 3mm/3mm
Ear
: within normal limit
Nose : nasal flare (+) found
Mouth : oral gastric tube (+) attached
Primitive reflex (+)
Respiratory system : unstable
CPAP (+) attached with FiO2 = 25%, PEEP = 6,
flow = 8L/ min, Sp. O2 = 93-95%
Respiratory rate = 72 times/ min, regular, rales (-)
Cardiovascular system: unstable
36
Result
Unit
Referral
Hemoglobin
Erythrocyte
Leucocyte
Thrombocyte
Hematocrite
MCV
14.4
4.18
10.85
234
43.80
104.80
g%
106/mm3
103/mm3
103/mm3
%
fL
13.4-19.8
4.71-5.14
9.3-30.
150-450
51-65
85-95
MCH
34.40
pg
28-32
MCHC
32.90
gr%
33-35
RDW
14.30
11.6-14.8
MPV
9.50
fL
7.0-10.2
PCT
0.22
PDW
10.2
fL
0.60
0.400
50.90
40.30
7.80
5.53
4.37
0.85
0.06
0.04
%
%
%
%
%
103/L
103/L
103/L
103/L
103/L
Differential
Eosinophil
Basophil
Neutrophil
Lymphocyte
Monocyte
Neutrophil absolute
Lymphocyte absolute
Monocyte absolute
Eosinophyl absolute
Basophyl absolute
1-6
0-1
37-80
20-40
2-8
5.5-18.3
2.8-9.3
0.5-1.7
0.02-0.70
0.1-0.2
37
Result
Unit
Referral
pH
7.292
pCO2
38.9
mmHg
38-42
pO2
170.7
mmHg
85-100
HCO3-
18.4
mmol/L
22-26
Total CO2
19.6
mmol/L
19-25
Base excess
-7.6
mmol/L
(-2)- (+2)
Sp. O2
Blood Glucose
99.3
79.7
7.35-7.45
%
mg/dL
< 200
Diagnosis
:
Respiratory distress ec. DD/ - Hyaline Membrane Disease
-
Neonatal pneumonia
38
: unstable
Procalcitonin = 0.22
Respiratory distress ec. DD/ - Hyaline Membrane Disease
-
Neonatal pneumonia
39
Neonatal pneumonia
40
atelectasis
: stable