Case Report

Monday , January 25th 2016

Team on duty :
Dr.Joko Siswanto ( Jaga 1 )
Dr.Haji Ifradin Pinim ( Jaga 2 )
Dr.Mohan siddiq ( Jaga 3 )
Dr.Raja M Purba ( jaga 3 )
Dr. M Reza ( Jaga 4 )
Dr. Reza F ( jaga 4 )
Dr.Ahmad Muhtadi ( Jaga 5 )
Dr.Iskandar ( Jaga 6 )

Patient identity
Name : Sari Putri
Age : 5 days
Sex : Girl
Address : Alue pinueng, langsa timur Kota langsa
Body Weight : 2700 gr
MR : 107 87 92
Phone Number : 0852 761 31678
Admission Time : 06.00 AM

Time Response

Chief complain
Hypersalivation after birth

Present illness history :

Patient was referred from Langsa district hospital to Zainoel Abidin
Hospital Emergency Room with chief complaint hipersalivation after birth,
cyanotic (-), Vomited after breast milk (+), distention (-), fever (-) Patient was
born with normal labour and with aterm pregnancy, crying spontaneously.
Hystory ANC (+) by midwife. Birth body weight 2.700 gr. Patient is the third child
and there is no history of such disease in the family.

Physical examination:
 Vital Sign
General Appearance : moderately
Suckingrefex : (+), weaknees
Grasping refex : (+), weakness
Crying : (+), weakness
Pulse : 156 beats / min
Respiratory rates : 58 breaths /min
Body temperature : 36,8 oC

L/S at oral region

OGT (+) was unable to get inserted to gaster , Hipersalivation (+)

L/S at the abdomen region

I : symmetrical, distention (-), bowel countour (-), schapoid type
A : bowel sound (+),decrease
P : smooth
P : tymphani (+), liver dulnes (+)

L/S at anorectal region

I : Anal (+)

Assessments:
Esophageal atresia type A

Management
Stop oral intake
Upright sitting position
Suction oral / 30 minutes
IVFD Rl 270 cc/24 jam
Resuscitation
20 cc/kgbb x 2,7 kg 54 cc/h
Inj. Cefotaxime 150 mg
OGT hypersaliva (+)
Catheter urine
Routine Laboratory examination
Radiology Examination

Laboratory result
Hb : 16,5 gr/dl
WBC : 12,9 /ul
Thrombocyte : 582 /ul
Ht : 46 %
CT : 8 minutes
BT : 3 minutes
Sodium : 141 mmol/L
Potassium : 4,7 mmol/L
Clorida : 99 mmol/L
Ureum : 66 mg/dl
Creatinin : 0,41 mg/dl

Radiology result
Baby gram:
The was cardiomegali
There was OGT until cervical 4th
 There was no gastric air
There was gasless to the distal

Diagnosed
Esophageal atresia type A

Consult to Pediatric Surgery Division :

Hospitalize
Prepare for esofagostomy + gastrostomy today