Students in charge :Felix, Jesicca, Andriana, Ifada, Benny, Tjok , Maretha, Onza, Viaditya, Yusa, Ardhian

Name : Baby. Mrs. EPAge : 12 hoursGender: MaleAddress : Jl Panglima Sudirman 73 MalangAdmitted to hospital: 12 December 2013Registry No. : 11148xxx

FatherName: Mr. SAge: 41 years oldOccupation: masseuseEducation: Senior High SchoolIncome: 500.000MotherName: Mrs. LHAge: 31 years oldOccupation: masseuseEducation: Senior High SchoolIncome: 500.000

Anamnesis (Heteroanamnesis from his mother)Chief complaint: New Born Baby

History of present illnessSpontaneous breech delivery, cloudy amniotic fluid, PROM for 4 days, cried, AS 7-9.

Medical HistoryANC atprimary health care center every month.History of pregnancyDM (-), hipertention (-), bleeding (-), massage (-), drugs (-), herbal medicine (-), fever (-), fluor albus (+) from beginning of pregnancy until 5th month, trauma (-)History of DeliverySpontaneous breech birth delivered by doctor.Gestational age 30-32 weeks Birth wight 1250 grams, body lenght 38 cm.

General appearanceAllert, spontaneous breathing

Vital signsHeart rate: 140 x / minuteRespiratory rate: 40 x / minuteTemperature : 36.5C

Antropometrical status Length: 38 cmWeigth : 1250 g Head circumference: 27 cm

HeadSize and shape: normocephalusHair: thin black hairface: symetrical

eyes Conjungtiva : anemia -Sclera: icteric -Palpebra: edema -/-Subkonjungtiva bleeding (-) Strabismus -/-Sunken eyes (-)

Ears : normal shape, normal position, secretions (-)Nose : secretions (-) hemorrage (-), hyperemia (-)

Mouth: dry mucosa (-), cyanotic (-), Thorax: symetrical, retraction (-), deformities (-), - Heart :S1 S2 normal, reguler, murmur (-), gallop (-)Lungs : symetrical, retraction (-)breathing sound: v v v v v vRhonki - - Wheezing - - - - - - - - - -Abdomen : soefl, bowel sounds(+) meteorismus (-), Extremities : warm acral, CRT < 2 seconds,anemic - - , icteric - - , edema - -, cyanotic - -- - - - - - - - Genetalia : within normal limits

NeuromuscularPosture 2Square window 1Arm recoil 2Popliteal angle 2Scarf sign 2Heel to ear 1

Physical MaturitySkin 1 Lanugo 2Plantar surface 2Breast 2Eye/Ear 1Genitalia 1Equal to 30 ~ 32 weeksLubchenco P10 - 25

1 minutesAppearance 1Pulse 2Grimace 1Activity 2Reflex 1

Total 75 minutesAppearence 2Pulse 2Grimce 1Activity 2Reflex 2

Total 9

HEMATOLOGYHb: 10.10 (11.4-15.1)RBC: 3.78x106 (4.0-5.0)WBC: 22.11x103 (4.7-11.3)Hematocrites: 29.20% (38-42)Thrombosites: 226 x 103(142-424)MCV: 77.2 (80-93)MCH: 26.7(27-31)MCHC: 34.6 (32-36)RDW: 13.3 (11.5-14.5)Eosinofils: 0.3% (0-4)Basofils: 0 % (0-1)Neutrophils : 85.4(51-67)Lymphosites: 7.9% (25-33)Monosites: 5.6% (2-5)

Pre-term/VLBW/AGA

O2 wardInfant warmerUmbilical careThermoregulationIM Vit. K 1x1 mggentamisin 1x1 OD/S zalfASI 8x15 cc

Vital Signs ( Pulse Rate, RR, Temp)Oxygen SaturationRespiratory distress

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