Patient Identity

Name
: By Darmawati
Sex
: Boy
Age
: 1 days old
Address
: Pango Raya, Kec. Ulee Kareng
Kota Banda Aceh
Phone
: 085360008900
CM
: 1 05 84 95
Body Weight
: 3100 gr
Time Admission : 12.03 PM

Chief Complaint
Born without anal
Present illness history:
Patient consult from pediatric division with a
chief complaint born without anal. helped by
a doctor . History of antenatal care (+) with
midwife. There was no history of feces come
out with urine. History of vomit (-)

Physical examination
Vital Sign
General Appearance
Sucking Reflex
Grasping Reflex : (+)
Crying
Pulse
Respiratory rates
Body temperature

: good
: (+)
: (+)
: 136 beat / min
: 57 breath /min
: 36, 5 oC

Localize state :
At abdominal region
Inspection : Distention (--) , symmetrical ,Bowel
Contour (-) Hiperemis suprapubic(-)
Auscultation : Bowel sound (+)
Palpation : soepel (+)
Percusion : Tympani, liver dullness (+)
At anorectal region
Inspection : Anal (-) ,Bucket handle (-), anal dimple
(+), perineal fistula (+),
mediana raphe (+)

Diagnose:
Anal imperforate with perineal fistula
(mediana raphe)

Management
Stop oral intake
IVFD RL 300cc/24 hour 12,5 cc/hours
Ceftriaxone 150 mg
OGT clear
Urinary Catheter

 Catheter urine 5 cc/hours

Time
15.00
16.00
17.00
18.00
Laboratory examination
Radiology examination

Volume (cc)
2 cc
3 cc
3 cc
5 cc

Laboratory examination
Hemoglobin
: 18,3 gr/dl
White Blood Count : 19.000/ul
Platelets
: 272.000/ul
Hematocrit
: 52%
BT/CT
: 7/2
Sodium
: 137 mmol/L
Potassium
: 5.6 mmol/L

Radiology examination:
Baby Gram :
Dilatation of Bowel

Diagnose
Low level anal imperforate with perineal
fistula (ICD 10 CM Q42.2)
Planning:
Consult to pediatric surgery division
Minimal PSA

Intra Operative
Identification anal dimple area
Found mediana raphe fistula (perineal fistula)
Performed incision 1 cm at mediana raphe
Incision deepened until found rectum
Rectum stump opened, performed rectoanal
anastomosis to neo anal

Post operation diagnose:

Low level anal imperforate with perineal
fistula (ICD 10 CM Q42.2)

Follow Up
Date

22/7/2015
POD 3

HR : 148
beats/minute
RR : 39 x/minute
T : 36,5 C
a/r Abdomen:
I: simetrical,
distension (-) , stoma
production (+),
vital,feces (+)
A: bowel sound (+)
P. liver dullness (+)

Low level
anal
imperforate
with perineal
fistula (ICD
10 CM
Q42.2)

Breast
feeding
- IVFD 4:1
300cc/24
hours
- Ceftriaxone
inj.150mg/12
hr
- Metamizol
sodium inj.
50 mg /8 hr