ANAMNESIS

Chieft Complaint

Body looks yellow

 HISTORY OF ILLNESS

On Hospital

• Her parents bring the patient to the pediatriciant PKU for routine post-
maternity control.
• However, when examined her skin appears yellow.
• Patients brestmilk strong, cry, and active.
• 5-6 x defecated (yellow, mucus (-), blood (-)) and urine is normal.
• The patient is advised to do further therapy
 HISTORY OF PAST ILLNESS

Conclusion:
Conclusion: there areno
there are history
historyofofpast
pastillness
illness that relatedtoto
that related
current illness
current illness
 HISTORY OF ILLNESS IN FAMILY

History of icterus neonatus : recognized (her father)

History of seizure : Denied
History of alergy : Denied
Blood Type of mother :B Rh (+)
Blood Type of father :A

Conclusion: there is a history of illness in family that correlated with

patient’s disease
 PEDIGREE

Tn. G 28 years old Mrs. A 27 years old

: Icterus neonatus

Conclusion : there is illness is inherited

 HISTORY OF PREGNANCY

Mother with P1A0 is pregnant at 27 years old. Mother began to

check pregnancy and routinely control to the doctor. During
pregnancy the mother does feel nausea, vomiting and dizziness
that interfere with daily activities. During pregnancy there is no
history of trauma, bleeding, infection, and hypertension during
pregnancy.

Conclusion : history of pregnancy was good

 HISTORY OF DELIVERY

The mother gave birth to her baby assisted by a doctor with a sectio
caesarea delivery. 40+2 weeks pregnancy age, baby born with body weight
3440 grams with body length 50 cm and head circumference 35 cm. At the
time of birth the baby cries instantly, there is no congenital defect at birth.

Conclusion : history of delivery was not good

HISTORY OF POST DELIVERY

The baby girl was born crying, active motion, red skin color, not
blue and not yellow skin color, got milk on first day, urination
and defecated less than 24 hours

Conclusion : history of post delivery was good

 HISTORY OF ENVIRONMENT

The patient lives at home with her parents and her old sister
and her old brother. Cheramic-floored patient houses, walled walls,
tile roofs, ventilation, bathrooms in the house, water source from
PDAM.

Conclusion : there is no risk factors for transmitted disease

 HISTORY OF VACCINE

• At that time of examination, the mother was bring

KMS.
• The patient has received the basic vaccine, there are
Hepatitis B (0) Vaccinations are obtained at the PKU
Muhammadiyah hospital.

Conclusion : history of vaccine was good

 HISTORY OF FEEDING

Age 0 - 5 days

• Exclusive breastmilk

Conclusion : history of feeding from quality and quantity was good

 Physical Examination

 General appearance
General appearance : Crying strong, active moving

 Vital Sign
Heart rate : 124x/ menit
Respiratory Rate : 28x/ menit
Temperature : 36,8º C
 Nutrisional status

- Weight : 3240 grams

- Lenght : 50 cm
- Head Circumference : 35 cm
- Chest Circumference : 32 cm

Conclusion : The patient's nutritional status was good

 Physical examination
• Skin examination
Color : yellow, from face, neck, abdomen until arm and
lower extremity (Jaundiced kramer 4)
The skin looks like a leather paper, cracked in, invisible
vein
Skin turgor: <2 sec (good)
Moisture: moist
Edema (-) does not exist

• Conclusion : the examination of skin is yellow

13
Kesan : Berat badan lahir sesuai masa kehamilan
Gafik Lubchenko

12/14/2018 Impression: Birth weight according to pregnancy 14

 PEMERIKSAAN KUSUS
Neck : No enlargement of lymph node and increase jugular venous, look yellow (+)
Chest : Simetris, retration (-), miss the motion (-), and look yellow (+)
• Heart
Inspeksi : The ictus cordis is not visible
Palpasi : Ictus cordis not strong lift
Perkusi : sound “redup”
Auskultasi : sound of cor I-II reguler, bising jantung (-)
• Lung
Inspeksi : Simetris, retraksi intercostal (-/-), retraksi
subcostal (-/-), retraksi substernal (-), retraksi suprasternal (-)
Palpasi : Simetris kanan kiri, There is no missed breath
Perkusi : sonor
Auskultasi : Vesicular (+/+) normal, rhonki (-/-), wheezing (-/-)

Conclusion : Neck,and Chest look joundiced

Stomach : Inspeksi : Datar, tali pusat kering, look yellow
Auskultasi : Peristaltik (+) normal
Perkusi : Timpani (+)
Palpasi : Supel, massa abnormal (-), nyeri tekan (-),
turgor kulit menurun (-), acites (-)
Liver : Hepatomegali (-)
Spleen : Splenomegali (-)

Conclusion : the examination of Stomach look yellow

 Genitalia

• Normal, Labia majora cover the labia minora

•Anus (+)

Result : Genitalia examination there are within normal limits

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12/14/2018 17
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 12/14/2018
Ektremitas
Anggota Gerak Superior Inferior
Tonus normotoni normotoni
Reflek primitif(moro,rooting,hisap) + +

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sendiri2
Sianosis -/- -/-

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Cap refill < 3 detik < 3 detik

Permukaan plantar kaki Garis2 pd

seluruh telapak
kaki

Result : Extremity examination there are within normal limits

18
 PHYSICAL EXAMINATION

Head : Normochephal
Eyes : CA (-/-), ScIera icteryc (+/+), edema palpebra (-/-), reflek cahaya (+/+)
isokor (+/+), decreased tears (-),
Nose : Sekret (-), epistaksis (-), nafas cuping hidung (-/-)
Ears : Sekret (-), hiperemis (-)
Mouth : Stomatitis (-), perdarahan gusi (-), sianosis (-), pharynx hiperemis (-),
dry lips (=)
Skin : Warna sawo matang, Pucat (-), Ikterik (+), Sianosis (-), turgor kulit (< 2
detik)
Lymph nodes : Tidak didapatkan pembesaran limfonodi
Muscle : Tidak didapatkan kelemahan, atrofi, maupun nyeri otot
Bone : Tidak didapatkan deformitas tulang
Joints : Gerakan bebas

Conclusion: positive on sclera icteryc and skin of joundiced

 Pemeriksaan Bilirubin

BILIRUBIN
Bilirubin total 19,4 mg/dL ( <11,7)
Bilirubin direk 0,3 mg/dL ( <1,2 )
Bilirubin Indirek 19,1 mg/dL (0-0,75)

Gol. Darah : A
Rhesus :+

20
 Infant at medium risk

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12/14/2018 21
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 Assesment
• Hiperbilirubinemia indirek
et causa DD :
- Polisitemia
- Defisiensi G6PD
- Sferositosis
- autoimun hemolitik

22
 Planning
• Routine blood examination
• Check bilirubin reset after phototherapy

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12/14/2018 23
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 Terapi
• Fototerapi continous 48jam sampai bilirubin <
15mg/dl
• Cek ulang bilirubin post fototerapi 48 jam kemudian
• Kebutuhan cairan ASI 160ml/kgBB/hari + 10 %
 3,2 kg x 160 ml/kg/hari = 512 ml/hari
 Intake 50 ml/ 3 jam

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12/14/2018 24
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 Fototherapy

1. Menggunakan panjang gelombang 425-475 nm.

2. Intensitas cahaya yang biasa digunakan adalah 6-12
mwatt/cm2 per nm.
3. Cahaya diberikan pada jarak 35-50 cm di atas bayi.
4. Jumlah bola lampu yang digunakan berkisar antara 6-8 buah,
terdiri dari biru (F20T12), cahaya biru khusus (F20T12/BB) atau
daylight fluorescent tubes .
 Rencana pengelolaan
• Monitor KU dan tanda vital
• Monitor intake dan output cairan

26
THANK YOU
TINJAUAN PUSTAKA
 IKTERUS
• Ikterus (jaundice) terjadi apabila terdapat
akumulasi bilirubin dalam darah, sehingga kulit
dan atau sklera bayi tampak kekuningan
Patofisiologi
 IKTERUS IKTERUS
FISIOLOGIS PATOLOGIS
ikterus yang timbul
pada hari kedua dan
- terjadi sebelum umur
ketiga yang tidak 24 Jam
mempunyai dasar
patologis

kadarnya tidak
melewati kadar yang
-Setiap peningkatan kadar
membahayakan atau bilirubin serum yang
yang mempunyai memerlukan fototerapi
potensi sebagai
“kern ikterus
 ETIOLOGI
 Produksi yang berlebihan
 Gangguan dalam proses uptake dan konjugasi
hepar
 Gangguan transportasi
 Gangguan dalam ekskresi
 Gangguan sirkulasi enterohepatik
Faktor Resiko
Ikterus patologis dapat disebabkan oleh keadaan

• Hemolisis akibat inkompatibilitas ABO atau

isoimunisasi rhesus, defisiensi G6PD, sferositas
herediter dan pengaruh obat
• Infeksi, septikemia, sepsis, meningitis, infeksi
saluran kemih, infeksi intrauterin
• Polisitemia
• Ekstravasasi sel darah merah, sefalhematom,
kontusio, trauma lahir
• Ibu diabetes
• Asidosis
• Hipoksia/asfiksia
• Sumbatan traktus digestivus yang
mengakibatkan peningkatan sirkulasi
enterohepatik
 KRITERIA DIAGNOSTIK IKTERUS
PATOLOGIS
• Timbul dalam 24 jam pertama kehidupan
• Bilirubin total/indirek untuk bayi cukup bulan ≥ 13
mg/dl atau bayi kurang bulan ≥ 10 mg/dl
• Kadar bilirubin direk > 2 mg/dl
• Peningkatan bilirubin > 5 mg/dl dalam 24 jam
• Ikterus menetap pada usia > 2 minggu
• Ikterus yang terjadi akibat hemolisis
• Terdapat faktor resiko
Penegakan Diagnosis
metode Kramer yaitu

Kramer 1 : kuning pada daerah

kepala dan leher
Kramer 2 : kuning sampai badan
atas (pusar atas )
Kramer 3 : kuning sampai badan
bawah (lutut dan atau
siku )
Kramer 4 : Kuning sampai
pergelangan
kaki dan tangan
Kramer 5 : kuning seluruh tubuh
(telapak tangan dan kaki)
 PENATALAKSANAAN
Tata laksana Awal Ikterus Neonatorum menurut WHO
• Mulai terapi sinar bila ikterus diklasifikasikan sebagai
ikterus berat.
• Tentukan apakah bayi memiliki faktor risiko berikut:
berat lahir < 2,5 kg, lahir sebelum usia kehamilan 37
minggu, hemolisis atau sepsis
 Fototherapy

1. Menggunakan panjang gelombang 425-475 nm.

2. Intensitas cahaya yang biasa digunakan adalah 6-12
mwatt/cm2 per nm.
3. Cahaya diberikan pada jarak 35-50 cm di atas bayi.
4. Jumlah bola lampu yang digunakan berkisar antara 6-8 buah,
terdiri dari biru (F20T12), cahaya biru khusus (F20T12/BB) atau
daylight fluorescent tubes .