Patient identity:Name: By. ZuriatiAge : 2 days oldSex : GirlAddress : Desa Nga, Lhoksukon. Aceh Utara MR: 1038723Father Phone: 085359899456Weight: 2800 gramPatient came at: 02.30 PM

Chief complain: Born without anal Presenting history: Patient was referred by district hospital Sigli with chief complain born without anal. Patient was born with normal labour and with post aterm pregnancy. The parents knew that the baby hasn't anal after he was born . History of vomitus was present and history of hipersalivation (+). There was no history of delayed meconium more than 24 hour.

Physical examination:Vital Sign General Appearance : moderatelySucking reflex: (+), weakneesGrasping reflex: (+), weaknessCrying : (+), weakness Pulse : 140 beats / minRespiratory rates : 38 breaths /minBody temperature: 36,8 oC Localize state : At abdominal region I : distention (-), symetrical , Darm Contour (-)P : seopel, defans muscular (-) P :Timpany (+), liver dullness (+)A : bowel sound (+) weakness

L/S at the hemithorax region

06/07/14

Thorax examinationRight hemithoraxLeft hemithoraxAuscultationVesiculer, ronchi (+)Vesicular, ronchi (+)

At ano rectal Inspection : anal dimple (+), bucket handle (-), At vagina: meconium (+)

06/07/14

06/07/14

06/07/14

Assessment: Anal imperforated with rectovaginal fistulaSusp Esophageal atresia

ManagementStop oral intakeIVFD 4:1 280 cc/24 hoursOGT (suction per 1 hour)Aminofusin 60 cc/ 24 hourBody up 450Inj. Ceftriaxone 150 mgInj. Ranitidine 2,5 mgLaboarorium examination Radiology examination

Laboratory results: Hb: 16.2 gr/dlWBC: 19.800 /ulTrombocyte: 184.000 /ulHt: 46 %CT: 7 minutesBT: 3 minutesSodium: 133 mmol/LPotasium: 5.2 mmol/LChloride: 96 mmol/LUreum: 74 mg/dlCreatinine: 1.43 mg/dlBlood glucose ad random: 276 mg/dl

Radiology Result :Baby Gram: Tip of OGT until thoracal 10 Dilatation of gastricDistribution of air until distalHomegen appeareance of the right hemithorac

Diagnose:Esophageal atresia with fistel tracheosofageal ( type C )High level of anorectal malformation with rectovagina fistulaBronchopneumonia at the right thorac.

Consult to Pediatric Surgery divisionHospitalize in NICUEchocardiografiThoracotomy anastomosis Eosofagus + Devided Colostomi Urgency

06/07/14

Follow Up

DateSOAP2-2-2015AD 2 (-)Vital Sign General Appearance : moderatelySucking reflex: (+), weakneesGrasping reflex: (+), weaknessCrying : (+), weakness Pulse : 138 beats / minRespiratory rates : 40 breaths /minBody temperature: 37,2 oC Ar.hemithoraks regionAuscultation vesicular (+), Ronchi(+) Esophageal atresia with fistel tracheosofageal ( type C )High level of anorectal malformation with rectovagina fistulaBronchopneumonia at the right thorac.Stop oral intakeIVFD 4:1 280 cc/24 hours OGT (suction per 1 hour) Aminofusin 60 cc/ 24 hourBody up 450Inj. Ceftriaxone 150 mgInj. Ranitidine 2,5 mg Observasion Urine out putEchocardiografi Prepare for Thoracotomy anastomosis Eosofagus + Devided Colostomi after optimalization and post operative care in ICU pediatric with ventilator