C/F/6 mo

746353
 Chief Complaint : Red current jelly stool

It had been suffered by the patient since 3 days

before admitted to Adam Malik Hospital. The s
ymptom was followed by suddenly crying with
out any stimulating, and intermittenly. History
of vomitting since 2 days ago with yellowish co
lor, fever (+) 2 days ago, urinating (+) Normal.
Patient was in breast feeding diet with out any
additional supportive diet.
Present State

Awareness : Alert
HR : 120 x/i
RR : 28x/i
T : 37,2 C
BW : 6000 gr
Generalized State

Head : No abnormalities was found

Neck : No abnormalities was found
Chest : No abnormalities was found
Abdomen : in localized state
Genitalia : male, No abnormalities was found
Extremities: No abnormalities was found
Localized State
Abdomen :
I : Symmetrical, distention (+), visible bo
wel movement (-), visible bowel contour
(-).
P : Tenderness (-), muscular rigidity (-) d
ance sign (+), sausage like mass (+) o/t l
eft hypocndrium.
P : Tymphani, liver dullness (+).
A : Peristaltic (+) increased
DRE :
Perineum usual, tight AST, slippery muc
ous, ampula was collapsed, pain (-).
Gloves : red current jelly stool (+)
01/20/2021
Laboratorium
Hb/ Ht/L/ T : 8,0 / 25 / 6.950/ 602.000
Na/K/Cl : 134 / 2,3 / 102
Ur/Cr : 13/ 0,4
Random Blood Glucose : 46
Chest X-Ray
Abdominal X-Ray
Working diagnose
Susp. Intussusception + Hipoglikemia +Hiponatre
mia + Hipokalemia + Anemia
Treatment
Nill per mouth
IVFD Dextrose 5 % NaCl 0,225% 20 gtt/i mikro
NGT installation  came out greenish 10 cc
Urine catheter  came out clear yellow 10 cc, UOP 7
cc/hr
Inj ceftriaxone 150 mg/12hr
Hypoglikemia Correction : 5cc/kgbw  30 cc with dex
trose 10% per bolus
Hypokalemia correction : 0,75 meq/Kgbw with Kcl 4,5
meq in 13 cc D5% for 3 hours
Inj vit K 3 mg IM
Hb Correction : (10-8) (6)(4) cc = 48 cc PRC
Prepared for Exploratory Laparotomy
At the operating theatre
Patient in supine position, under general ETT anesthesia, aseptic and antisepti
c procedure.
The transverse supra umbilical incision was made, cutis, subcutaneous, fascia
was opened, muscle cut, peritoneum was opened came out serous fluid abou
t 10 cc, found dilatation of small bowel.
Explore start from lig. treitz to rectum found intussuseption with ileocolica ty
pe.
Decided to performed milking procedure gently, milking procedure was succe
ss, the trapped bowel was release. Intususeptum were consist of terminal ileu
m, caecum, appendiks, and ascending colon.
The color of bowel was reddish, hematoma (+), tactile stimulating -> peristalti
c (+). The bowel was compressed with warm saline.
Appendix was edematous, erectile, followed by appendectomy with double li
gation.
Lymph node was found at ileal mesentrial, decided to lymphadenectomy then
sent for histopathological examination.
The abdominal cavity swap with moist gauze until clean.
The operation wound was closed layer by layer leaving 1 drain at rectovesica
pouch.
Operation was done.
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