EMERGENCY CASE REPORTS

Monday , May 30th, 2011

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
 Monday, May 30th 2011

Ambulation : 1 Patients

Hospitalized : 4 Patients

Observation : - Patients
Operated : 1 Patients
Death : - Patients

Total : 5 Patients
 No. 5
Name : 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 Status
Moderate 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 Status
Anal Region
I : Seen no anal canal, anal dimple (+) skin color same with its vicinity
P : 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

 Semester I
• Makalah I
• Makalah II Semester IV
• Stase 8 Sub Bagian
Makalah III
(Nasional)

Makalah Akhir

• DSTC Semester IX
• Perioperatif

Semester X
• Panutan
• Santun
• Jujur
• Empati