35 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 hadn’t 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 : the neonate was born spontaneously outside RSUP HAM, helped by a midwife and immediately crying. Birth weight (BW) = 1860 gr, birth length (BL) =
35CHAPTER 3CASE REPORTHistory taking :Chief complaint :
Shortness of breathA male newborn, named DNM, was admitted to the
neonatal unit at General HospitalHaji Adam Malik Medan !S"# HAM$ on
%une &, '()* with shortness of breath asthe chief complaint+
,he neonate was born on the same da-, about one hour
beforeadmission to the hospital with .estational a.e / 0(10' weeks+
,his complaint hadbeen e2perienced since deli3er- with no histor-
of bluishness+ 4hen admitted, thenewbornhadweakcr-, less of
acti3it-, andweaksuckle+ "rinate 5$ normal+Meconium hadn6t been -et
e2creted+Histor- of pre.nanc- : the neonate is the first bab- born
to the '(1-ear1old mother+Histor- of diabetes 1$, .estational
diabetes 1$, h-pertension 1$, fe3er durin.pre.nanc- 1$, #!7M 1$+
Histor- of mother with fe3er 1$, herb 8 medication use1$+Histor- of
deli3er- : theneonatewasbornspontaneousl-outside!S"#HAM,helped b- a
midwife and immediatel- cr-in.+ 9irth wei.ht 94$ / ):;( .r,
birthlen.th 9$#lannin. :NaCl (+&E loadin. )(ccCk.94/ '(cc
immediatel-$, A9G anal-sis, 9G test!ollo"#u$ :38%une &'th
('&)S Shortness of breath 5$O CNS s-stem : stableHead :
anterior fontanelle is still palpable, sensorium :CMA-e : li.ht
refle2 5$ normal, isochoric pupils B 0mmC0mmAar : within normal
limitNose : nasal flare 5$ foundMouth : oral .astric tube 5$
attached#rimiti3e refle2 5$!espirator- s-stem : unstableC#A# 5$
attached with Di7' / '*E, #AA# / ;,flow / : adeFuate#eripher- :
warm e2tremities 5$, edema 1$, C!, G0 secs+Metabolic s-stem :
stableAbdomen : tender, peristaltic mo3ement 5$ normal,li3erC
spleen / impalpableHematolo.ic s-stem : unstable#ale 1$, bleedin.
1$
