Morning Report

 Name : By. Ny. S

 Age : 2 days
 Sex : male
IDENTITY  Address : Punggaluku
 Admission : June, 3th 2018
 Doctor in charge : dr. Rabiul Awal, Sp.B
KBD
  Chief complain :
Hasn’t anal hole
 Anamnesis :
HISTORY
since birth 2 days ago in primary health with the help of tocologist. The
TAKING baby was born with enaugh months , immediately crying and weight
3000gr. When mother got pregnant she never did check up with
tocologist and USG check up. The patient has no anal hole when checked
evidently. Another complaint vomited (+) since last night continuously
after breastfeeding, blown (-), cough (-) , urinary in last night.
History of the same symptom in family (-)
 Generalized State
General Condition :
Head : Normally
moderete illness Face : Normally
Neck : Normally
Conciousness :
Chest : Normally
Composmentis, Abdominal :Localized
State
Vital Sign :
Back : Normally
RR : 42x/m Upper Limb : Normally
HR : 140 x/m Lower Limb : Normally
T : 37,8 0c / axilar
 LOCALISATED STATE

Regio abdominal

Inspection : convex, follow the motion of breath,

Auscultation : Peristaltic was Normally
Palpation : distended abdomen (+).
Percussion : Tympani (+)
Others : hasn’t anus since birth
 CLINICAL
DOCUMENTATION
 Routine
Blood
PLAN OF
DIAGNOSTIC
X-ray
Abdomen
Routine blood
X-ray Abdomen
 Atresia Ani
DIAGNOSE
MANAGEMENT

Non Farmacology Farmacology

•Rest •IVFD
•NGT pair •Inj. Antibiotic

Consult To digestive surgery