EMERGENCY CASE REPORTS

Monday , May 30th, 2011

SURGERY DEPARTMENT

EMERGENCY ROOMWAHIDIN

SUDIROHUSODO GENERAL HOSPITAL

MAKASSAR

EMERGENCY CASE REPORT

WAHIDIN SUDIROHUSODO HOSPITALMAKASSAR

Monday, May 30th 2011

Ambulation : 1 Patients

Hospitalized : 4 Patients

Observation : - Patients

Operated : 1 Patients

Death : - Patients

Total : 5 Patients

No. 5Name : Ch. A Sex : Male

Age : 2 days No. Reg : 46 88 32

Chief complaint : No Anal Canal

History taking : Suffered since 2 day before admitted to ER, there was history of vomiting with greenish coloring liquid.. There was history of using traditional drug during pregnancy.

Micturation : Normally

General StatusModerate illness / well nourish / conscious

Vital Sign PR : 130 x/mnt, strong, reguler, RR : 32 x/mnt, symmetric L=R,

thoracoabdominal type. T(Ax) : 36,7 °C

Local StatusAnal RegionI : Seen no anal canal, anal dimple (+) skin color same with its vicinityP : tenderness (-), tumor mass (-)

Laboratory Result

WBC : 3.92 x 103 / μL

RBC : 4.87 x 106 / μL

HGB : 18.8 g/dL

HCT : 50.5%

PLT : 156 x103/ μL

CT / BT : 9‘00” / 3’00”

Blood Sugar : 96 mg/dl

Ureum : 21 mg/dl

Creatinin : 0,3 mg/dl

GOT / GPT : 27/12 μ/L

BNO

Cross Table

WORKING DIAGNOSIS : MAR

MANAGEMENT : • IVFD• Apply catheter • Apply NGT• Medicaments• Report to senior pediatric surgeon advice : plan for Divided Colostomy (Colon

Sigmoid)

Operating Procedure

• Patient laid in supine position under GA.• Desinfection and draping procedure • Perform transversal incision at lower left region

abdomen, deepen until peritoneum• Identification of colon sigmoid• Perform divided colostomy• Bleeding control• Close wound layer by layer• Operation finished

POST OP DIAGNOSIS : Atresia Ani High position

PROGNOSIS : Good

FOLLOW UP : Vital sign

• Makalah I • Makalah II • Stase 8 Sub

Bagian Makalah III (Nasional)

Makalah Akhir

• DSTC • Perioperatif

• Panutan• Santun• Jujur• Empati

Semester I

Semester IV

Semester IX

Semester X

Thank you