By.

E / M / 19 Hours
78.34.69
• Chief Complaint: Sac on the abdomen
• It had been suffered by the patient since born, 6 hours before admitted to Adam
Malik Hospital. Lump was came out from belly button and covered with thin sheath
of tissue. History of fever (-), vomit (-), cough (-), cyanotic (-), meconium (+) at first 24
hours, and micturition (+) normal. Patient was the first child, delivered by normal
delivery. Pregnancy history : aterm 36 weeks, crying immediately after birth with
weight 3200 gr and length 47 cm. His mother had a regular ANC with midwife and
obstetrician during pregnancy. History of consumption of unprescribed drug, other
traditional herbs and radiation exposured was denied. Patient has no history of
congenital disease in family. Patient was referred from district hospital.
Present State:
• Awareness : Alert, crying loudly
• Heart Rate : 120x/mnt
• Respiratory Rate: 32 x/mnt
• Temperature : 36,50 C
• Body weight : 3200 gr
Generalized State
• Head & Neck : No abnormality was found
– Sunken fontanelle (-)
– Eye: anemic conjunctival (-), icteric sclera (-/-), sunken eyes (-/-)
– Nose: saddle nose (-)
– Ear: low set ear (-)
– Mouth: Macroglossia (-)
– Throat and esophageal: no abnormalities
• Chest : No abnormality was found
• Abdomen : In localized state
• Genitalia : Male, no abnormality was found
• Vertebrae : No abnormality was found
• Anal : No abnormality was found
• Extremity : No abnormality was found
Localized state : Abdomen

• I : Sac on the umbilical with yellowish

color, sized ᴓ 8x4x3 cm, firm consistency,
smooth surface, viable content, ruptured (-),
pus (-)
• A : Soepel
• P : Tymphani
• P : peristaltic (+) normal
• DRE :
– Perineum normal, TSA tight, smooth mucosal
surface, ampulla was empty.
– Gloves  meconium (+), blood (-), mucus (-)
Chest X-Ray
 Laboratory Finding :

– Hb / HT / WBC / PLT : 16,5 / 52 / 17.400 / 197.000

– N/L/M/E/B : 66,6/ 18,5/ 9,4/ 4,2/ 1,3
Working Diagnosis
Omphalocele
Treatment at the ER:
• Insertion of OGT  came out clear liquid 10 cc
• Insertion of catheter with OGT 3.5 Fr  came out clear yellow, initial 4 cc, UOP 5
cc/hour
• IVFD NaCl 0.9% 192cc/24hours  8cc/hour  8 microdrips/min
• Antibiotic injection  Cefotaxime 150 mg/12h

• Plan:
– Conservative treatment  Escharotic therapy
– Consult pediatric departement to rule out other congenital anomalies.