Neonatal Respiratory Dist...

A 4 day old baby on the 4th day of treatment with complaints that he is currently increasingly congested and weak. Babies tend to whimper, not cry and are not active.

 

Delivery history: Baby born SC (gestation 35-36 weeks/preterm),

The baby cried loudly immediately after birth, slightly weak muscle tone (+), reddish skin (+), preterm (+), active movements (+), dry amniotic fluid (+), meconium (-), micturition (-) , congenital abnormalities (-), retraction (-)

 

Physical examination: Weak, BB: 2010 gr, PB: 45 cm, HR: 167x/minute, RR: 50-55x/minute, SpO2: 96-97% on CPAP

 

Head: Head (-), NCH (-) cyanosis (-), ENT: complete, no signs of infection, Thorax: cor/ S1 S2 reg mg- g-. Pulmo: SN ves rh -/- wh -/-, bilateral retraction, Abdomen: supel (+), BU (+) N, Extremities: CRT < 2 sec, cyanosis -/-, Anus (+)

 

Diagnosis:

1. Neonatal RDS

2. Early Onset Neonatal Sepsis

3. LBW - Prematurity

 

Therapy:

Aminofluid 6% 1.4 ml/hour, D10% 5 ml/hour, Cefotaxim 2x100 mg, Ampicillin 2x100 mg, Gentamicin 10 mg/36 hours, breast milk 4x15 ml