CASE REPORT

Thursday, July 23th 2015

Team on duty
dr. M. Nazir Tambunan
dr. Tommy Rivelino
dr. Raja Raharja MP
dr. Bobby HE Fermi
dr. Andre Feisal Nst
dr. Herdi Gunanta S
dr. Ifani SR

(Jaga 1)
(Jaga 2)
(Jaga 3)
(Jaga 4)
(jaga 4)
(Jaga 5)
(Jaga 5)

Patient identity
Name
: By. Samiaty
Age
: 2 d.o
Sex
: Boy
Address
: Mns. Teupin Keubeue.Lhoksukon
Phone
: 081361906162
CM
: 1059028
dy weigt
: 2600 gr
Admission time: 23.20 WIB
Time Respone
Date/h Examinati Laboratory
Radiology
Hour of
our
on hour
Examination Examination Diagno
patien
stics
t came
Sen Result Send Result
to ER
d
23 July
2015/
23:20
Wib

23:20 Wib 22:45 03:00

Wib
Wib

02.25 Wib

02:58
Wib

Date/ho DPJP
ur
patient
out from
ER
Dr
Muntadh
ar SpB,
SpBA

Chief complaint
Born without anal
Patient illnes history
The patient was reffered from Cut Meutia distric hospital to Zainoel Abidin
Emergency Room with a chief complaint born without anal. There was
Hypersalivation and vomiting since he was born. The vomite was clear. The

patient was born with aterm pregnancy and help by midwife with spontan partus.
History of ANC (+) at midwife, history of vomiting (-).
Physical examination
Vital Sign
Sucking reflex
Grasping reflex
Crying
Pulse
Respiratory rates
Temperature

: weak
: weak
: weak
: 136 beats/ min
: 44 breaths/min
: 36,7oC

L/S Oral region

L: Hypersalivation (+), OGT Cant performed
L/S at abdominal region
I
: Distension (+), darm contour (+),
A
: Bowel sound (+) decrease
P
: Soepel
P : Tymphani, Liver dullness (+)
L/S at ano rectal region :
Inspection :Anus (-), anal dimple (+), fistel (-), bucket handle (+)
There was no abnormality at another part of body

Assessments:
1. Anal imperforate without fistel
2. Susp Esophageal atresia

Management
Stop oral intake
IVFD 4:1 maintenance 250/24 hour 11 cc/hours
Dehidration 10%x 2500= 250 cc.
11 cc+250 cc = 261 cc/6 hour= 43,5 cc/hours
Urinary Catheter 2 cc/hours,clear
OGT can not performed
Cefotaxime inj. 100 mg
Metamizole sodium inj. 40 mg
Laboratory examination
Radiology examination

Laboratory examination
Haemoglobin
White Blood Count
Platelets
Hematocrit
BT/CT

: 13,6 gr/dl
: 25.200 /ul
: 352.000/ul
: 40%
: 7/2

Diagnose
1. Anal imperforate Low level without fistel
(ICD 10 CM Q42.3)
2. Esophageal atresia (ICD 10 CM Q39.1)
Consult to pediatric surgery division
Colostomy emergency
Gastostomy