MORNING REPORT

PATIENT IDENTITY

Name : Baby AF Gender : Male Age : 19 days Address : Lamongan Ethnic : Javanesse

SUMMARY OF DATABASE

Chief of complaint: Bloated stomach

History of present illness

Bloated stomach since 1 days before admission, the stomach felt stiff, he often “gumoh” every feeding since 1 weeks ago. Defecation everyday >3times a day, but today just once and spurting, soft consistency, yellowish, mucus (-), blood (-). Febris (-), he still can feeding. He look like pushing every defecation and urination.

History of past illness: His mom told that he never complaining this condition.

History of birth: SC/Preterm (35-36 weeks)/3000gram/spontaneous cry Post natal direct defecation (+) black colour.

History of nutrition Breast milk (+)

History of immunization Hepatitis B, Polio

PHYSICAL EXAMINATION

Vital Sign: Blood Pressure : 0 mmHg Pulse Rate :155 x/minutes Respiration Rate : 42x/minutes Temperature : 36.8 ⁰C Body weight :3700 gram

Generalis Examination:

• Head/Neck: anemis -/-, jaundice -/-, cyanosis -/-, dyspnoe -/-, sunken eye -, sunken fontanel -

• Chest:• Inspection: symmetrical, retraction -/-• Palpation: normal/ normal• Percussion: sonor/sonor• Auscultation: vesicular/vesicular, Rh -/-, Wh -/-

• Cor:• Inspection: Vussorue cardiac, Ictus cordis(-)• Palpation: ictus (-), thrill (-)• Percussion: the normal of heart• Auscultation: S1/S2 single murmur -, gallop –

• Abdomen:• Inspection: convex, darm contour (-), prominent umbilicus (-)• Palpation: distended, H/L hard to evaluated• Percussion: tympani• Auscultation: bowel sound (+)

• Extremity :

• warm, dry, red, CRT < 2”

• RT :• Sfingter anal tone (+), collapse of ampulla recti (-), yellowish stool is spurt, mucus (-), blood (-).

LABORATORIUM Hb : 14.8 Lekosit : 18.4 Lymphocyte : 47.6 Neutrophyle : 33.4 Monocyte : 8.6 Eosinophyl : 4.1 Basofil : 6.3

Hct : 44.4 MCH : 34.90 MCHC : 33.30 MCV : 105 RDW : 14 Platelet : 714 Chloride : 99 Kalium : 5.3 Natrium : 131 Hs CRP: -

Radiology

CLUE AND CUE Baby, 19 days old Abdominal distended Pushing every defecation and urination. Febris Leukocytosis Louder bowl sound RT : spurting stool (+) Ro : colon dillatation

Problem List

Enterocolitis Hirschprung’s Disease

PLANNING DIAGNOSIS

Colon in loop

Diagnosis

Hirscprung’s Disease

PLANNING THERAPY

IVFD D10 0.5 NS 200 cc/24 hours Rectal Tube, wash out NaCl hangat 10 cc/kgBB Oro Gastric Tube

Consul pediatric surgery OGT, LLD, Rectal Tube + washout