Patient identity

Name : Aril Maulanda

Age : 9 days

Sex : Boy

Address : Simpang Puet Kuala Meulaboh

Body weight : 1600 gr

CM ` : 1194907

HP (Father) : 082360310943

Time Arrived : 00.20 Wib

Time Response
Chief Complaint

Abdominal distension

Patient Illness History

The patient was referred from Chut Nyak dhien Meulaboh district hospital to Zainoel Abidin emergency
room with chief complaint of abdominal distension a day after born.

The patient was born aterm pregnancy and helped by obstetrician with secsio caesaria.

There was history of antenatal care

There was no history of late meconium, do defecation since 6 days ago.

The patient was the 3th child from 3 children with born weight 1600 gram

Urinate in normal limit.

There was history of vomiting.

There was no history of fever.

Physical examination :

Vital Sign

Sucking reflex : (+) weakness

Grasping reflex : (+) weakness

Crying : (+) weakness

Heart Rate : 136 beats/min

Respiratory Rate : 40 breaths/min

Temperature : 37,30 C

L/S at the abdominal region

I : Symmetrical, distension (+), hyperemis

periumbilical(+), darm countour (-), darm

 steifung (-)

A : Bowel sound (-)

P : Smooth

P : Tymphani

Rectal touche :

Tonus sphincter ani : Tight

Recti Ampulla : Feces (+)

Recti mucose : Smooth

Glove : Blood (-), feces (+)

Pulled out the finger : Blew out feces (-)

Assessments :

Meconium peritonitis

• Management

• IVFD 4 : 1  300 cc/24 hours

• OGT decompresion

• Urine catheter  initial urine 5 cc

• Laboratory examination (lysis)

• Radiology Examination

• Radiology result

Baby gram :

• Air distribution not until rectum

• Dilated of bowel (+)

 • Free air(+)

• Diagnose :

1. Meconium peritonitis

Consult to pediatric surgery Division :

• Laparatomy exploration emergency today