Pediatric Surgery Report

Saturday, June 6th, 2020

Patricia/Sinung/Silmina/Fatimah/Khairuli/Dipo
 Patients Distribution
No Identity Sex Age Diagnosis Problem Managements Exp
1 Surya M 13 yo Generalized peritonitis due to susp Infection Fasting ER
perforated acute appendicitis (K35.2) Dehydration Decompressive NGT
Moderate dehydration (E86.0) + Hypoalbuminemia IVFD RL loading 1000 cc, maintenance 2100 cc, rehydration 4000 cc
Hypoalbuminemia (E88.09) First 8 hrs : 2000 + 700 – 1000 = 1700 cc/8 hrs  212,5 cc/hrs
Second 16 hrs : 2000 + 1400 = 3400 cc/16 hrs  212,5 cc/hrs
Ceftriaxone 2 x 1 gr IV
Metronidazole 3 x 500 mg IV
Paracetamol 4 x 500 mg IV
Albumin correction 20% 100 cc IV
Urethral catheterization
Planning : exploratory laparotomy + appendectomy.
2 Sahrul Kusnadi M 16 yo Generalized peritonitis due to susp Infection Fasting ER
perforated acute appendicitis (K35.2) Decompressive NGT
IVFD RL loading 1400 cc, maintenance 2500 cc, rehydration 5600 cc
First 8 hrs : 2800 + 833,3 – 1400 = 2233,3 cc/8 hrs  279,1 cc/hrs
Second 16 hrs : 2800 + 1666,6 = 4466,6 cc/16 hrs  279,1 cc/hrs
Ceftriaxone 2 x 1 gr IV
Metronidazole 3 x 500 mg IV
Paracetamol 4 x 500 mg IV
Planning : exploratory laparotomy + appendectomy.
3 Mrs. Lilis’ baby F 4 do Total bowel obstruction at the level of Bowel obstruction Fasting ER
ileum dt susp ileal atresia (Q41.2) Dehydration Decompressive NGT
Moderate dehydration (E86.0) Infection IVFD RL loading 44 cc (2 times), maintenance 264 cc, rehydration 220 cc
First 8 hrs : 110 + 88 – 88 = 110 cc/8 hrs  13,75 cc/hr
Second 16 hrs : 110 + 176 = 286 cc/16 hrs  17,8 cc/hr
Cefotaxim 2 x 110 mg IV
Paracetamol 4 x 33 mg IV
Hyperkalemia correction
Planning : exploratory laparotomy + ileal resection and anastomosis.
 Patients Distribution
No Identity Sex Age Diagnosis Problem Managements Exp
4 Mrs. Diane M 12 do Necrotizing Enterocolitis std IIB (K55.30) Infection Fasting Anturium
Awalunisa’s Decompressive OGT
baby (I) IVFD RL 2000 cc/24 jam
Meropenem 3 x 100 mg
Fluconazole 1 x 7,5 mg
Planning diagnosis : fecal occult blood test, routine abdominal xray evaluation.
5 Raihan Ashari M 7 yo Acute appendicitis post open Infection IVFD KaEN Mg3 88 cc/hr Kana ward
appendectomy Ceftriaxone 2 x 1 g
Paracetamol 4 x 1 g
6 Mrs Lela’s baby M 9 do Anorectal malformation with Intestinal obstruction Divided colostomy Anturium
rectourethral fistule post divided
colostomy
3 PATIENTs

EMERGENCY PATIENTS
 Surya / M / 13 yo (6-11-2006) / 50 kg
MR : 0001836453 – 20022169 / ADM : 6-6-2020 / Emergency Room
Consultant : dr. Dikki Drajat, SpBA(K)
Chief complaint : abdominal pain

Patient suffered from abdominal pain since 10 days prior to admission. The complain was accompanied by
fever. The pain was initially felt on the right lower side of the abdomen and then eventually felt on the whole
abdomen after 5 days. The patient also complained of abdominal distention since 5 days prior to admission. Nausea
and vomiting were denied. The patient had only 2 bowel movements within 10 days, and the latter was assisted by
Microlax®, but only small amount of feces was defecated. History of change of bowel habit nor recurrent abdominal
pain was denied.
Due to these complaints, patient was taken to Majalaya hospital, underwent laboratory and radiologic
examination. He was then reffered to Hasan Sadikin hospital since fully occupied room.
Patient didn’t have
 Physical Examination

Consciousness : alert
PR : 104 x/m, RR : 22 x/m, T : 37,2 oC, Sat 98% room air.
Head : anemic conjunctiva & icteric sclera were absent, dry mucosa of lips.
NGT : minimal, clear.
Thorax : symmetrical shape and shape, retraction was absent.
Lungs : vesicular breathing sound, rales and wheezing were absent.
Heart : regular heart sound, no murmur.
Abdomen :
I : distended, bowel contour and movement were not visible.
A : normal bowel sound
P : pain at whole abdomen, Muscular rigidity (+)
P : shifting dullness (+)
Digital rectal examination : normal anal sphincter tone, mass (-), pain in all direction.
Handglove : fecal material (+)
Urine production : 150 cc (initially), dense  after loading, urine output 1,5 cc/kgBW/hour.
Extremity : warm, capillary refill time < 2”
Clinical Pictures
Clinical Pictures
 Laboratory Results

• Hb : 11,1 • AST : 17
• HT : 32,7 • ALT :7
• Leukosit : 4.760 • Alb : 2,22
• Platelet : 402.000 • GDS : 108
• Bas/Eo/Stab/Seg/Lim/Mo : 0/2/0/66/23/11 • Natrium : 132
• PT : 11,7 • Kalium : 3,7
• APTT : 28,0 • CRP : 18,91
• INR : 1,04
• Ureum : 14,6
• Creatinine : 0,56
Thorax AP xray
RSHS, 6-6-2020
Plain abdominal xray
RSHS, 6-6-2020
Working Diagnosis :
Diffuse peritonitis due to susp perforated appendicitis (K35.2) + Moderate dehydration (E86.0) + Hypoalbuminemia
(E88.09)

Management :
Fasting
Decompressive NGT
IVFD RL loading 1000 cc, maintenance 2100 cc, rehydration 4000 cc
First 8 hrs : 2000 + 700 – 1000 = 1700 cc/8 hrs  212,5 cc/hrs
Second 16 hrs : 2000 + 1400 = 3400 cc/16 hrs  212,5 cc/hrs
Ceftriaxone 2 x 1 gr IV
Metronidazole 3 x 500 mg IV
Paracetamol 4 x 500 mg IV
Albumin correction 20% 100 cc IV
Urethral catheterization
Planning : exploratory laparotomy + appendectomy.
Patient underwent Exploratory Laparotomy + ascites evacuation + adhesiolysis + omental biopsy + parietal
peritoneal biopsy, on June 7th, 2020. Surgeon : dr. Patricia.

Intra operative findings :

– 2500 cc of clear, yellowish peritoneal fluid.
– Omentum adhesive to anterior abdominal wall.
– There was grade I adhesion between Small intestine to small intestine and small intestine to omentum.
– Omentum, peritoneum, small intestine, colon and mesenterium were filled with multiple whitish tubercle.
– Appendix was antececal in position, no perforation was found.
– Omental and peritoneal biopsy were performed.
 Intra opetive findings

Intestine and mesenterium Omentum

 Intra opetive findings

Appendix Peritoneum
 Intra opetive findings

Peritoneal fluid Post operative scar

Post operative diagnosis :
Diffuse peritonitis due to peritoneal tuberculosis post exploratory laparotomy + adhesiolysis + omental and parietal
peritoneal biopsy + Hypoalbuminemia
 Sahrul Kusnadi / M / 16 yo (15-1-2004) / 70 kg
MR : 0001836474 – 20022172 / ADM : 6-6-2020 / Emergency Room
Consultant : dr. Dikki Drajat, SpBA(K)
Chief complaint : abdominal pain

Patient suffered from abdominal pain since 5 days prior to admission. The pain was initially felt in the
epigastrium then migrated in the right lower part of the abdomen the day after and then followed by pain in all area
of the abdomen since 2 days prior to admission. The pain was accompanied by fever. The patient also suffered from
nausea since 2 days prior to admission, without any vomiting. The patient was unable to defecate for 3 days. The
last bowel movement was soft in consistency, without accompanying blood nor mucus during defecation. History of
bloody stool and mucoid stool were denied. Complain of urination was denied.
Due to these complaints, patient was taken to Immanuel hospital, given IV fluid an antibiotics, underwent
laboratory and radiologic exams, and was diagnosed as peritonitis. Since there was no room available, patient was
then reffered to Hasan Sadikin hospital.
 Physical Examination

Consciousness : alert
PR : 96 x/m, RR : 22 x/m, T : 37,8 oC, Sat 98% room air.
Head : anemic conjunctiva & icteric sclera were absent, dry mucosa and lips.
Thorax : symmetrical shape and shape, retraction was absent.
Lungs : vesicular breathing sound, rales and wheezing were absent.
Heart : regular heart sound, no murmur.
Abdomen :
I : flat.
A : decreased bowel sound
P : pain in all area of abdomen, muscular rigidity (+)
P : tympanic (+)
Digitiral rectal examination : normal anal sphincter tone, mass (-), pain in all direction.
Handglove : fecal material (+)
Urine production : 100 cc (initially), after rehydration urine output 1,2 cc/kgBW/hour
Ekxtremity : warm, capillary refill time < 2”
Clinical Pictures
 Laboratory Results

• Hb : 13,9 • AST : 86
• HT : 39,8 • ALT : 31
• Leukosit : 19.910 • Alb : result not yet available
• Platelet : 476.000 • GDS : 96
• Bas/Eo/Stab/Seg/Lim/Mo : 0/0/0/88/6/6 • Sodium : 133
• PT : 21,5 • Pottasium : 4,2
• APTT : 40,7 • CRP : 38,26
• INR : 1,45 • Anti SARS Cov 2 : non reactive
• Ureum : 107,6
• Creatinine : 4,61
 Plain abdominal xray
Immanuel Hospital, 6-6-2020
Thorax AP xray
RSHS, 6-6-2020
Plain abdominal xray
RSHS, 6-6-2020
Working Diagnosis :
Diffuse peritonitis due to susp perforated appendicitis (K35.2) + Moderate dehydration

Management :
Fasting
Decompressive NGT
IVFD RL loading 1400 cc, maintenance 2500 cc, rehydration 5600 cc
First 8 hrs : 2800 + 833,3 – 1400 = 2233,3 cc/8 hrs  279,1 cc/hrs
Second 16 hrs : 2800 + 1666,6 = 4466,6 cc/16 hrs  279,1 cc/hrs
Ceftriaxone 2 x 1 gr IV
Metronidazole 3 x 500 mg IV
Paracetamol 4 x 500 mg IV
Planning : exploratory laparotomy + appendectomy.
 Mrs. Lilis’ baby / F / 4 do (2-6-2020) / 2,2 kg
MR : 0001836489 – 20022173 / ADM : 7-6-2020 / Emergency Room
Consultant : dr. Dikki Drajat, SpBA(K)
Chief complaint : abdominal distention

Patient suffered from abdominal distention since birth that became worse since 1 day prior to admission. The
complaint was accompanied by brownish, foully odor vomiting. The patient vomited everytime it was breastfed. The
mother then halt the breastfeeding. The patient had its meconium passed when it was 3 days old. The meconium
was pale, and only a few in quantity. There was fever and decreasing urine production since 1 day prior to
admission. The baby loss its body weight during the complaints.
The baby was spontaneously delivered by P3A1 mother, 38 weeks of gestational age, assisted by midwife,
spontaneously cried after birth. Birth weight was 2.5 kg. History of cyanotic lips was denied. The mother had routein
antenatal care in midwife and experienced antenatal sonographic examination by obstetrician. During the exam, the
obstetrician stated that the pregnancy had no problems. Due to these complaints, the patient was taken to Cililin
hospital, but then referred to Hasan Sadikin hospital since there is no pediatric surgeon available.
 Physical Examination

Consciousness : state 4
HR : 158 x/m, RR : 52 x/m, T : 37,7 oC, Sat 98% room air
Head : sunken major fontanella, sunken eyes, anemic conjunctiva & icteric sclera were absent, dry mucosa of lips.
OGT : 160 cc, fecal production.
Thorax : symmetrical shape and shape, retraction was absent.
Lungs : vesicular breathing sound, rales and wheezing were absent.
Heart : regular heart sound, no murmur.
Abdomen :
I : distention, vein ectasias, bowel contour and movement were unvisible, absent abdominal wall edema, absent
abdominal wall hyperemia.
A : increased bowel sound
P : soft
P : tympanic
Digitiral rectal examination : normal anal sphincter tone.
Handglove : pathologic meconium
Urine production : 3 cc (initially), after loading urine output 2 cc/kgBW/hour
Ekxtremity : warm, capillary refill time < 2”
Clinical Pictures
Clinical Pictures
 Laboratory Results

• Hb : 15 • AST : 34
• HT : 43,8 • ALT : 18
• Leukosit : 15.200 • Alb : 3,24
• Platelet : 321.000 • GDS : 88
• Bas/Eo/Stab/Seg/Lim/Mo : • Natrium : 137
• PT : 10,9 • Kalium : 6,6
• APTT : 0,97 • CRP :6
• INR : 34,00 • Anti SARS Cov-2 : Reactive
• Ureum : 267,0
• Creatinine : 2,24
Thorax AP xray
RSHS, 6-6-2020
Plain Abdominal xray
RSHS, 6-6-2020
Working Diagnosis :
Total bowel obstruction at the level of small bowel due to jejunal atresia (Q41.2) + Severe dehydration (E86.0) +
Hyperkalemia (E87.5) + susp Covid 19 infection (U07.2)

Management :
Fasting
Decompressive NGT
IVFD RL loading 44 cc (2 times), maintenance 264 cc, rehydration 220 cc
First 8 hrs : 110 + 88 – 88 = 110 cc/8 hrs  13,75 cc/hr
Second 16 hrs : 110 + 176 = 286 cc/16 hrs  17,8 cc/hr
Cefotaxim 2 x 110 mg IV
Paracetamol 4 x 33 mg IV
Hyperkalemia correction
Planning : exploratory laparotomy + ileal resection and anastomosis.
1 PATIENT

CONSULT PATIENT
 Mrs. Diane Awalunisa’s baby (I) / M / 12 do (26-5-2020) / 2.5 kg
MR : 0001835354 – 20033070 / ADM : 26-5-2020 / Anturium
Consultant : dr. Dikki Drajat, SpBA(K)
Consultation from Pediatric Departement on working diagnosis : gastric dilatation.

Chief complaint : distended abdomen

Patient suffered from distended abdomen since 3 days prior to consultation. The complain was accompanied
by unable to defecate since 2 days ago. The patient also suffered from history of vomiting 3 days and 9 days prior to
consultation, after given formula milk. Fever was denied. The patient was fasted since 9 days prior to consultation.
The patient given formula milk during the first 3 days of its life. The patient is currently on CPAP mode of
oxygenation for the last 3 days.
Patient was delivered by P1A0 mother, through cesarean section due to fetal distress, premature rupture of the
membrane for 2 days, and gemelli. Apgar score was 7-9, history of peripartum cyanotic was denied. The mother is
confirmed Covid-19 patient. The patient already tested for swab 2 times and the result was negative, so the patient
moved to Anturium ward.
 Physical Examination

Consciousness : state 4
HR : 132 x/m, RR : 52 x/m, T : 37,4 oC, Sat 98% on CPAP FiO2 35%, 10 lpm, pressure 2 mmHg
Head : anemic conjunctiva & icteric sclera were absent, moist mucosa lips.
OGT : 20 cc, brownish.
Thorax : symmetrical shape and shape, retraction was absent.
Lungs : vesicular breathing sound, rales and wheezing were absent.
Heart : regular heart sound, no murmur.
Abdomen :
I : distention, bowel contour and movement were not visible.
A : decreased bowel sound
P : soft
P : tympanic
Digitiral rectal examination : normal anal sphincter tone.
Handglove : fecal material (+)
Ekxtremity : warm, capillary refill time < 2”
Clinical Pictures
Clinical Pictures
 Laboratory Results
05-06-20, RSHS

• Hb : 11,3 • Natrium : 131

• HT : 31,1 • Kalium : 5,4
• Leukosit : 4.950 • CRP : 14,62
• Platelet : 4.000
• Bas/Eo/Stab/Seg/Lim/Mo : 0/2/2/43/39/9
Plain abdominal xray
RSHS, 6-6-2020
Plain abdominal xray
RSHS, 6-6-2020
Working Diagnosis :
Necrotizing Enterocolitis grade IIB (K55.30) + neonatal sepsis (A41.0)

Management :
Fasting
Decompressive OGT
IVFD RL 2000 cc/24 jam
Meropenem 3 x 100 mg
Fluconazole 1 x 7,5 mg
Planning diagnosis : fecal occult blood test, routine abdominal xray evaluation.
2 PATIENTs

POST OPERATIVE PATIENTS

 Raihan Ashari / L / 7 yo (06/8/2012) / 50 kg
MR : 0001836311-20022162 / ADM : 5-6-2020 / Kana
Consultant : dr. Kurniawan Oki, SpBA
Patient was admitted in Kana ward on working diagnosis : Acute appendicitis post appendectomy.

During our shift :

S : abdominal pain is decreased, vomiting and fever were absent.

O : Consciousness : alert, PR 90x/m, RR 20x/m, Suhu 36,7 C

NGT : unproductive
Thorax : vesicular breathing sound, no additional breathing sound.
Abd : flat, soft, BS weak.
Urine production : 1 cc/kgBB/hr
 Raihan Ashari / L / 7 yo (06/8/2012) / 50 kg
MR : 0001836311-20022162 / ADM : 5-6-2020 / Kana
Consultant : dr. Kurniawan Oki, SpBA
A : Acute appendicitis post open appendectomy

P:
Post operative instruction : • Liquid diet
• IVFD KaEN Mg3 88 cc/hr
• Ceftriaxone 2 x 1 g
• Paracetamol 4 x 1 g
 Mrs Lela’s baby / L / 9 do (29-5-2020) / 2,5 kg
MR : 0001835939 / ADM : 2-6-2020 / Anturium
Consultant : Dr. dr. Rizki Diposarosa, SpBA(K)
Patient was admitted in Anturium ward on working diagnosis : Anorectal malformation with rectourethral fistule.

The patient underwent Divided colostomy on June 6th, 2020, surgeon : dr. Sinung, SpB

Intra operative findings :

• Clear peritoneal fluid.
• Sigmoid colon dilatation.
• Divided colostomy was constructed on proximal sigmoid colon.
 Mrs Lela’s baby / L / 9 do (29-5-2020) / 2,5 kg
MR : 0001835939 / ADM : 2-6-2020 / Anturium
Consultant : Dr. dr. Rizki Diposarosa, SpBA(K)
 Mrs Lela’s baby / L / 9 do (29-5-2020) / 2,5 kg
MR : 0001835939 / ADM : 2-6-2020 / Anturium
Consultant : Dr. dr. Rizki Diposarosa, SpBA(K)
Post operative diagnosis :
Anorectal malformation with rectourethral fistule post divided colostomy.
THANK YOU