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    Bb. Mrs. Dewi/7d.o/ 3 KG / MR 1-43-51-07 Admitted On July 27 2019 at 20.00 PM

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    monyet65
    This document summarizes a medical case involving a 3 kg, 7 day old female infant admitted with complaints of bloated stomach for 5 days. Her history included infrequent, small bowel movements and vomiting after feeding. Initial examinations and lab tests revealed abdominal distension, normal vital signs, and abnormal liver and kidney function. Imaging showed possible intestinal obstruction. The working diagnoses were suspected Hirschsprung's disease, hyponatremia, and neonatal sepsis. Treatment included IV fluids, antibiotics, and rectal washouts. Consultation with pediatric surgery was placed for further evaluation.

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    Bb. Mrs. Dewi/7d.o/ 3 KG / MR 1-43-51-07 Admitted On July 27 2019 at 20.00 PM

    Uploaded by

    monyet65
    28 views10 pages
    This document summarizes a medical case involving a 3 kg, 7 day old female infant admitted with complaints of bloated stomach for 5 days. Her history included infrequent, small bowel movements and vomiting after feeding. Initial examinations and lab tests revealed abdominal distension, normal vital signs, and abnormal liver and kidney function. Imaging showed possible intestinal obstruction. The working diagnoses were suspected Hirschsprung's disease, hyponatremia, and neonatal sepsis. Treatment included IV fluids, antibiotics, and rectal washouts. Consultation with pediatric surgery was placed for further evaluation.

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    This document summarizes a medical case involving a 3 kg, 7 day old female infant admitted with complaints of bloated stomach for 5 days. Her history included infrequent, small bowel movements and vomiting after feeding. Initial examinations and lab tests revealed abdominal distension, normal vital signs, and abnormal liver and kidney function. Imaging showed possible intestinal obstruction. The working diagnoses were suspected Hirschsprung's disease, hyponatremia, and neonatal sepsis. Treatment included IV fluids, antibiotics, and rectal washouts. Consultation with pediatric surgery was placed for further evaluation.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    28 views10 pages

    Bb. Mrs. Dewi/7d.o/ 3 KG / MR 1-43-51-07 Admitted On July 27 2019 at 20.00 PM

    Uploaded by

    monyet65
    This document summarizes a medical case involving a 3 kg, 7 day old female infant admitted with complaints of bloated stomach for 5 days. Her history included infrequent, small bowel movements and vomiting after feeding. Initial examinations and lab tests revealed abdominal distension, normal vital signs, and abnormal liver and kidney function. Imaging showed possible intestinal obstruction. The working diagnoses were suspected Hirschsprung's disease, hyponatremia, and neonatal sepsis. Treatment included IV fluids, antibiotics, and rectal washouts. Consultation with pediatric surgery was placed for further evaluation.

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    2. Bb. Mrs. Dewi/7d.

    o/ 3 kg / MR 1-43-51-07
    Admitted on July 27th 2019 at 20.00 pm

    Chief Complaint: Bloated Stomache


    History:
    Her parent complained bloated stomache since 5 days before admitted. Bloating was due to her defecating
    every 2-3 days and each time the defecation comes out only slightly (1-3cc). She defecated greenish stool
    with soft consistency. The first time she defecate when she was 2 days old. She also vomited 2-3 times a day,
    the contents are green liquid, Vomiting every time breastfeeding, and reduced after OGT installed.
    History of Birth: she was born with SC (because of FD), BW 3 kg, crying immediately, she was first child,
    mother age 36 yo
    History of Antenatal: her mother often controls to midwife every month, once the 2x ultrasound with
    obstetrician specialist and said to be normal, history of fever during pregnancies (-), smell vaginal discharge
    during pregnancies (-), history of consuming drug during pregnancy (-).
    Vital sign
    oHR : 124 tpm
    oRR : 48 tpm
    oTax : 37,5 Co
    oSpO2 : 98% without O2 supply
    • Normocephaly (+) pale conjungtiva (-/-), sclera icteric (-/-), light reflex (+/), sunken eye
    Head/Neck (-/-), palpebral edema (-/-) OGT (+) 10 fr, production 10 cc with clear liquid
    • Swelling (-)

    • I : symmetric respiratory movement, retraction (-)


    • P : symmetric vocal fremitus
    Chest • P : sonor at all lung fields
    • A : vesicular breath sound, rhonchi (-), wheezing (-)

    • I : distension (+), venectation (+)


    Abdomen • A : bowel sound (+) 4-6 x/minute
    • P : tenderness (-), Hepar, mass, and lien not palpable, sausage sign (-), dance sign (-)
    • P : tympani (+)

    Extremities • warm extremities in all regions, CRT <3 s, edema (-/-)


    Local State
    USG Abdomen (20/07/2019)
    USG Abdomen (20/07/2019)
    Laboratory Findings 27/07/2019
    Examination Result Normal Value

    Hemoglobin 18,4 12,00-16,00 g/dl

    Leukosit 16,2 4,0-10,5 ribu/ul

    Eritrosit 5,40 3,90-5,50 juta/ul

    Hematokrit 53,3 37,00-47,00 vol%

    Trombosit 213 150-450 ribu/ul

    RDW-CV 17,2 11,5-14,7 %

    MCV 98,7 80,0-97,0 fl

    MCH 34,1 27,0-32,0 pg

    MCHC 34,5 32,0- 38,0 %

    Ureum 42 10-50 mg/dl

    Creatinin 1,46 0.6-1.2 mg/dl


    Laboratory Findings 27/07/2019

    Examination Result Normal Value

    SGOT 114 5-34


    SGPT 61 0-55
    Natrium 123 135-146 mmol/L
    Kalium 3,9 3,4-5,4 mmol/l
    Chlorida 88 95-100 mmol/l
    PT 14,9 Second
    APTT 38,7 Second
    Diagnosis
    Susp. Hirschprung disease + Hyponatremia +
    Sepsis Neonatorum
    Management
    Treatment in ER :
    • IVFD D10% 300cc + Nacl 3% 9cc/24 hours
    • Ceftriaxone inj 1 x 300 mg iv
    • Paracetamol Inj 3 x 30mg iv
    • Attach rectal tube
    • Washout 3x/24 hours with warm NS 20cc

    Consult to Pediatric Surgery:


    • MRS + joint with perinatology
    • Pro colon in loop

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