Case Report

Monday , January 25th 2016

Team on duty :
Dr.Joko Siswanto
(
Dr.Haji Ifradin Pinim
Dr.Mohan siddiq
(
Dr.Raja M Purba
(
Dr. M Reza
(
Dr. Reza F
(
Dr.Ahmad Muhtadi (
Dr.Iskandar
(

Jaga 1 )
( Jaga 2 )
Jaga 3 )
jaga 3 )
Jaga 4 )
jaga 4 )
Jaga 5 )
Jaga 6 )

Patient Identity
Name
: Shavira Maulidia
Age
: 10 Months old
Sex
: Girl
Address
: Panton Rawoh, Labuhan Aji Barat, Aceh Selatan
Body weight : 7100 gr
CM
: 1078791
Fathers phone
: 0853 7392 3080
Admission time
: 5.00 AM
Time response
Date/
Time
patie
nt
came
to ER

Examinati
on hour

26
Jan
2016

5.15

Laboratory
Examination

Radiology
Examination

Send

Resul
t

Send

Result

5.30

6.30

9.00

10.15

Time
of
Diagn
ostics

Date/ Time
patient out
from ER

DPJP

11.15

18.00
(PAPS)

Dr. Dian
Adi SpBA

Chief complaint
Abdominal distension
Patient illnes History
The Patient was referred from Teuku Peukan (Aceh Barat Daya) hospital
to Zainoel Abidin Emergency Room with a chief complaint abdominal
distension for 4 days. According to her mother, 1 week ago the baby
experienced vomiting and red currant jelly stool for 2 days. History of
greenish vomiting was present. There was history of colicy pain. History
of fever was present.

Physical examination
General appearance

: Moderate

Suckling Reflex
Grasping Reflex
Crying
Pulse
Respiratory rates
Body temperature

: (+) Weak
: (+) Weak
: (+) Weak
: 140 beats / min
: 32 breaths/min
: 36,7 oC

L/S at abdominal region :

I
: Distension (+), darm contour (+), darm steifung (+)
A
: Bowel sound (+) Increase
P
: Soepel, Palpable mass (+)
P
: Tymphani (+)

Digital Rectal Examination :

Sphincter ani
: Tight
Ampulla recti
: collapse, pseudo portio (-)
Recti mucose
: Smooth
Glove : Bloody discharge (-), feses (+)
Assessments:
Intussusception
Management
Stop Oral Intake
OGT decompression clear
Folley Catheter clear (initial 5 cc)
IVFD RL 100 cc x 7 = 700 cc
Inj. Cefotaxime 350 mg
Inj. Metamizole Sodium 150 mg
Laboratory examination
Radiology examination

Hour

Urine

06.00

10cc

07.00

12cc

08.00

12cc

09.00

14cc

10.00

12cc

11.00

12cc

12.00

14cc

Laboratory result
Hb
:
WBC
:
Platelet
Ht
:
CT
:
BT
:
Sodium
Potassium :
Chloride
:

9,4 g/dl Transfusion

14.200 /ul
: 615.000 /ul
33 %
7 minute
2 minute
: 136 meq/L
3,8 meq/L
102 meq/L

Radiology examination
USG : Target sign (+)
Diagnose :
1. Intussusception
2. Anemia

Consult to pediatric surgery division :

Laparotomy exploration emergency
(Patient refused medical advised 18.00 WIB)