Laporan kasus

1. CLINICAL CONFERENCE
NEONATOLOGY DIVISION
(New Case)
Januari 06th 2023
Ayu Nurliyana Pratiwi, Mohamad Jumatman/ Junior (presenter)
Muhammad Rifani, Rizna Ariani Said/ Madya
Kartika Setiawaty, Eunike Jaequeline S, Dian Anggraeni Hafid/ Senior

2. MR Number
Date of Birth
Admission Date
1008481
January 23th 2023
January 04st 2023
MEDICAL DIAGNOSIS
By. Mrs. N (Male)

4. A 9-day-old boy was referred from Bone Hospital with a diagnosis of Hydrocephalus + Respiratory
Distress of Newborn + High suspicion of sepsis + Full-term baby / Appropriate for gestational age
There was an enlarged head noticed from birth.
No fever, no seizures
No cough, no shortness of breath, there was history of shortness of breath while being treated at the
Bone Hospital.
No vomiting
Urination : normal, yellow
Defecation: normal

5. Pregnancy history
The first pregnancy, the mother pregnant at the age of 23 years old, routinely control
to primary health center and the first time she controls at the obstetrician at 7 months
of pregnancy. The mother routinely consume vitamins and supplements.
There was no history of herbal and drugs consumption during pregnancy.
There was no history of maternal illness during pregnancy. There was no history of
urinary tract infection, hypertension and diabetes mellitus during pregnancy.

6. Birth history
The baby was born by sectio caesarea for indications of fetal hydrocephalus. Full
term baby, immediately cry. The birth Weight was 3900 grams, Body Length was 54
cm, and head circumference was 44.2 cm.
Breastfeeding History:
Children drink formula milk from birth

7. History of Immunization:
Baby has not received any immunization
There was a history of having pets, such as cats or dog
There was no history of living in plantation areas
There was no family history of congenital abnormalities
There was history of being treated at Bone Hospital since birth and treated with
ampicillin and gentamicin for 9 days, oxygen nasal cannula for 8 days and drinking
formula milk via OGT

8. Vaccine
Frequency
Not yet given 0 1 2 3 4
Hep B V
BCG V
DPT V
Hib V
POLIO V
MMR V
Influenza V
Japanese Encephalitis V
PCV V
Varicella V
HepatitisA V
V

9. Vital Sign
General Status: active
Heart Rate :138 bpm
Temperature : 36,8 °C
Respiration Rate : 40 times/minute
SpO2 : 98%
Anthropometry
Birth weight: 3.900 gr
Current Birth weight: 3.400 gr
Birth length: 54 cm
Gestational age: aterm
Head circumference: 44,2 cm (Macrochephally, normal 32-37 cm)

10. Birth weight: 3.900 gr
Current Birth weight: 3.400 gr
Birth length: 54 cm
Gestational age: aterm
Head circumference: 44,2 cm
(Macrochephally, normal 32-37 cm)

11. Birth weight: 3.900 gr
Current Birth weight: 3.400 gr
Birth length: 54 cm
Gestational age: aterm
Head circumference: 44,2 cm
(Macrochephally, normal 32-37 cm)

12. There was macrocephaly.
The fontanel protrudes
There was sunset eye phenomenon
SSP :
No fever, no seizures
no temperature instability,
Sucking reflex, swallow reflex present
Respiration :
No retraction
Bronchovascular breath sounds
No rhonki and wheezing
Cardiovascular :
Regular pure 1/2 heart sound
No murmur
Warm acral, crt < 3 seconds
Gastrointestinal :
Not distended
Normal peristalsis
The liver and spleen are not palpable
defecation: normal, yellow
Metabolic : no edema on the lids. there was icterus,
cremer II
BAK : enough impression
Hematology : No pale and no bleeding manifestation

13. Downe score
 Respiratory rate 0
 Retraction 0
 Cyanosis 0
 Air entry 0
 Grunting 0
Total Score 0

14. LABORATORY FINDING
Laboratory
Bone Hospital
(26-01-2023)
NormalValue
WBC 15.800 5.0 – 21.0/μL
Hb 20,9 12.7 – 18,7 gr/dL
MCV 103 84 – 128 fL
MCH 36 24 – 30 pg
PLT 216.000 150.000 – 450.000/mm3
GDS 84 60 – 180 mg/dl
% Neut 12
% Lymph 2,1
% Mono 1,0

15. RADIOLOGY FINDING
Head MSCT without contrast from RSWS (05/02/2023)
Conclusion:
- There was an overview of Hidranencephaly

17. • Daily fluid requirements:
• 150 ml/kgBB/day = 510 cc
• Enter:
• 150cc/kgbb/day
• = 8 x 64 cc
• Stop antibiotics
Planning
• Consult to Neurosurgery Department