By.Ny.

W/M/2do
81.53.32
Chief Complain : Absence of anus

It has been suffered by the patient since born 2 days before admitted to Adam Malik
Hospital. The patient was delivered through spontaneous delivery by midwife. Patient
was aterm at 37 weeks, birth weight 3.100 gr, birth length 40 cm, cried spontaneously
after birth. The patient is the second child. History of fever (-), vomiting (+), micturition
was normal.
The mother had regular ANC by midwife. The patient’s mother giving birth at 30 years
old. History of smoking during pregnancy (-). History of unprescribed drugs consumption
and other traditional herbs during pregnancy was denied, congenital diseases in the
family was denied, radiation exposure was denied. Patient was treated from district
hospital and then referred to H. Adam Malik Hospital.
 Present State
• Awareness : Alert
• HR : 146 x / min
• RR : 48 x / min
• Temp : 36.8 ° C
• BW : 3100 gr
 Generalized state
• Head : no abnormalities found
• Neck : no abnormalities found
• Chest (cor) : no abnormalities found
• Abdomen : in localized state
• Genitalia : male, in localized state
• Anal : in localized state
• Vertebra : no abnormalities found
• Trachea : no abnormalities found
• Esophageal : no abnormalities found
• Renal : no abnormalities found
• Limb : no abnormalities found
Localized State

Abdomen
I : Symmetrical, distension (+),
visible bowel contour (-),
visible bowel movement (-)
A : Peristaltic (+) increased,
metallic sound (+)
P : Smooth, palpable mass (-),
tenderness (-), muscular
rigidity (-)
P : Hypertymphani, liver
dullness (+)
Localized State
Perineum : absence of anus, anal
dimple (+), flat bottom
(-), bucket handle (+),
midline raphe (+).
 Laboratory Finding

• Hb/Ht/L/Plt : 15.9/44/13.170/324.000
• Random Blood Glucose : 77
• Na/K/Cl : 150/3.7/107
• Ur/Cr : 41/1.59
• Rapid test Covid-19 : non reactive
Babygram
Knee-chest position
 WORKING DIAGNOSIS

Anorectal Malformation With Rectoperineal Fistula (Bucket Handle

type)
 Treatment at ER
- Nil per mouth
- O2 nasal canule 1L/i
- IVFD NS 0,225% : D5% = 100cc/kg/day = 3.100cc/24h = 129cc/per hour
- Insertion of OGT  came out greenish fluid, production 3 cc.
- Insertion of urinary catheter  came out clear yellow urine about 5 cc,
UOP 4 cc/hour.
- Antibiotic  Inj. Cefotaxime 150 mg/12h iv

Plan:
- Minimal PSA