By.

E/M/4hours
72.01.69
Chief Complaint : the intestine came out of the abdomen
It had been suffered since birth, 4 hours before admitted to
Adam Malik Hospital. History of vomitting (-), micturition
(+) normal. Patient was second child, born spontaneously
by midwife, aterm, crying loudly, meconium (+), with body
weight 3.000 gram. Mother antenatal care was regular by
midwife. History of unprescribed drug and herbal
consumption during pregnancy was denied. History of
previous congenital disease in family (-). Patient was
referred from district hospital.
•Present
  State :
Awareness : Alert
HR : 152 beats/minute
RR : 36 times/minute
T : 36,8C
BW : 3000 gram
Generalized State :
Head : no abnormality was found
Neck : no abnormality was found
Chest : no abnormality was found
Abdomen : in localized state
Genitalia : Male, no abnormality was found
Extremities : no abnormality was found
Localized State :
Abdomen :
I : small bowel and some large bowel outside the abdomen,
defect 2 x 2 cm right lateral to the umbilicus, bowel movement (+)
P : supple, muscular rigidity (-)
P : tymphani
A : peristaltic (+)

DRE : perineum as usual, sphincter ani was tight, smooth

mucous, ampula was empty.
Hand gloves : feces (-), blood (-), mucous (-).
Laboratory finding :
Hb/ Ht/L/ T : 16,5/49/9.250/508.000
Na/K/Cl : 135/6,3/104
Ur/Cr : 13/0,46
Random Blood Glucose : 60
Babygram X-Ray
Working diagnosis :
Gastroschisis
Management at ER :
• Nil per mouth
• IVFD Crystalloid
• Insertion of OGT came out clear fluid 5 cc
• Insertion of urinary catheter  UOP 3 cc/h
• Inj. Antibiotic
Plan :
• Hospitalized
• Diagnostic of other VACTERL
• Prepared for defect closure