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Patient identity:

Name : By. Zuriati


Age

: 2 days old

Sex

: Girl

Address

: Desa Nga, Lhoksukon. Aceh Utara

MR : 1038723
Father Phone : 085359899456
Weight : 2800 gram
Patient came at: 02.30 PM

Chief complain:
Born without anal

Presenting history:
Patient was referred by district hospital Sigli
with chief complain born without anal. Patient
was born with normal labour and with post
aterm pregnancy. The parents knew that the
baby hasn't anal after he was born . History
of vomitus was present and history of
hipersalivation (+). There was no history of
delayed meconium more than 24 hour.

Physical examination:
Vital Sign
General Appearance

: moderately

Sucking refex : (+), weaknees


Grasping refex : (+), weakness
Crying : (+), weakness
Pulse

: 140 beats / min

Respiratory rates

: 38 breaths /min

Body temperature : 36,8 oC


Localize state :
At abdominal region
I

: distention (-), symetrical , Darm Contour (-)

: seopel, defans muscular (-)

:Timpany (+), liver dullness (+)

: bowel sound (+) weakness

L/S at the hemithorax region


Thorax
examination

Right
hemithorax

Left hemithorax

Auscultation

Vesiculer, ronchi
(+)

Vesicular, ronchi
(+)

06/07/14

At ano rectal
Inspection : anal dimple (+), bucket
handle (-),
At vagina

06/07/14

: meconium (+)

06/07/14

06/07/14

Assessment:
Anal imperforated with rectovaginal
fistula
Susp Esophageal atresia

Management
Stop oral intake
IVFD 4:1 280 cc/24 hours
OGT (suction per 1 hour)
Aminofusin 60 cc/ 24 hour
Body up 450
Inj. Ceftriaxone 150 mg
Inj. Ranitidine 2,5 mg
Laboarorium examination
Radiology examination

Laboratory results:

Hb

: 16.2 gr/dl

WBC : 19.800 /ul

Trombocyte : 184.000 /ul

Ht

: 46 %

CT

: 7 minutes

BT

: 3 minutes

Sodium : 133 mmol/L

Potasium: 5.2 mmol/L

Chloride : 96 mmol/L

Ureum

Creatinine

Blood glucose ad random

: 74 mg/dl
: 1.43 mg/dl
: 276 mg/dl

Radiology Result :
Baby Gram :
Tip of OGT until thoracal 10
Dilatation of gastric
Distribution of air until distal
Homegen appeareance of the right
hemithorac

Diagnose:
Esophageal atresia with fistel
tracheosofageal ( type C )
High level of anorectal malformation
with rectovagina fistula
Bronchopneumonia at the right
thorac.

Consult to Pediatric Surgery


division
Hospitalize in NICU
Echocardiografi
Thoracotomy anastomosis Eosofagus
+ Devided Colostomi Urgency
06/07/14

Follow Up
Date
2-22015
AD 2

(-) Vital Sign

Esophageal
atresia with
: fistel
tracheosofage
al ( type C )
High level of
anorectal
malformation
with
rectovagina
fistula
Bronchopneum
onia at the
right thorac.

General
Appearance
moderately
Sucking refex
: (+),
weaknees
Grasping refex
: (+),
weakness
Crying
: (+),
weakness
Pulse
: 138
beats / min
Respiratory rates :
40 breaths /min
Body temperature :
37,2 oC

Ar.hemithoraks
region
Auscultation

Stop oral intake


IVFD 4:1 280 cc/24
hours
OGT (suction per 1 hour)
Aminofusin 60 cc/ 24
hour
Body up 450
Inj. Ceftriaxone 150 mg
Inj. Ranitidine 2,5 mg

Observasion Urine out


put
Echocardiografi
Prepare for Thoracotomy
anastomosis Eosofagus
+ Devided Colostomi
after optimalization and
post operative care in
ICU pediatric with
ventilator

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