Professional Documents
Culture Documents
• Patient identity
• Name : Birrul Walidain
• Age : 2 months old
• Sex : Boy
• Address : Blang Puuk Nigan Seunangan, Nagan Raya
• Body weight : 5,1 kgs
• CM : 1140413
• Father’s phone : 085210257219
• Admisssion Time : 24.57 WIB
Chief complaint
Abdominal distension
Patient illnes History
• The patient was referred from Meulaboh distric hospital to Zainoel Abidin Emergency Room
with a chief complaint abdominal distension since 3 days ago.
• According to the mother, since 3 days ago the baby can’t defecation and his abdomen
became distension.
• History of greenish vomiting (+)
• There was history of colicky pain
Physical examination
• Suckling Reflex : weakness
• Grasping Reflex : weakness
• Crying : weakness
• General appearance : Moderate
• Pulse : 140 beats / min
• Respiratory rates : 36 breaths/min
• Body temperature : 36,5 oC
L/S at abdominal region
• I : Distension, visible peristaltic (+).
• A : Bowel sound increase
• P : Musculaire rigidity (-), dance sign (+), Sausage like mass sign (+)
• P : Tymphani (+)
Assessments:
Abdominal distension due to
dd : 1. suspect intussusception
2. midgut volvulus
Management
• Stop Oral Intake
• IVFD 4:1 500 cc/24 hours
• Urinary Catheter : initial urine 10 cc
• NGT Decompression
• Inj. Ceftriaxone 250 mg
• Inj. Metamizole sodium 50 mg
• Laboratory examination
• Radiology examination
Laboratory result
• Hb : 7,5 g/dl transfusion
• White blood count : 10.500/ul
• Platelet : 277.000/ul
• Ht : 22 %
• CT : 7 minute
• BT : 2 minute
• Glucose ad random : 86 mg/dL
• Sodium : 138 meq/L
• Potassium : 4.4 meq/L
• Chloride : 96 meq/L
Hour Urine
01.00 8 cc
02.00 7 cc
03.00 8 cc
04.00 8 cc
05.00 10 cc
06.00 8 cc
07.00 7 cc
08.00 8 cc
09.00 8 cc
10.00 7 cc
11.00 8 cc
12.00 7 cc
13.00 8 cc
14.00 8 cc
Radiology Result :
Baby Gram
• Air distribution not until distal colon
• Dilatation of bowel
USG
• Pseudokidney sign (-)
• Target sign (-)
• Corkscrew (+)
Diagnose :
• Abdominal distension due to
dd : 1. suspect intussusception
2. midgut volvulus
• Anemia