Case Presentation Acute Abdomen Pediatric

CASE PRESENTATION Acute Abdomen

Created by :Devina 07120110064

Preceptor :Dr. Ulynar Marpaung, Sp.A

Faculty of MedicineUniversity of Pelita Harapan

Department of PediatricBhayangkara Hospital Tk. 1 Raden Said SukantoKramat Jati, East Jakarta

(Periode March 30th 2015 June 6th 2015) I. Patient IdentityName: An. DhDate, Birth Place: Jakarta, 30th November 2012Age: 2 year 4 monthGender: FemaleReligion: MoslemAddress: East JakartaMedical Record Number: 75-33-xx

II. Parents IdentityFatherName: Mr. GAge: 28 years oldReligion: MoslemEducation: High SchoolOccupation: LaborMotherName: Mrs. MAge: 26 years oldReligion: MoslemEducation: High SchoolOccupation: Housewife

III. AnamnesisDate of Admission at Hospital: 1st April 2015Date of Anamnesis & Examination: 2nd April 2015 16th April 2015Methods: AlloanamnesisPlace: Room no. 5, Anggrek 2 Ward, RS POLRI R Said Sukanto

IV. Chief ComplaintVomiting > 5 times a day, filled with fluid and food waste since 1 day before the admission.

V. Present Illness HistoryA 1 year and 4 months old girl with body weight 15 kg, came to RS POLRI R Said Sukanto ER at 2nd April 2015, with a chief complain of vomiting. Patient vomit more than 5 times a day, filled with fluid and waste food. The patient complained of nausea, bloating, and abdominal pain since 1 day before the admission. Patient also has fever lasts from 3 days, non-continuously, with the highest temperature 40oC at night. She has brought to the health center for treatment 2 days ago. The doctor gave her paracetamol and domperidone but no sign of improvement.

VI. Past illness HistoryEnteritis.

VII. Allergic HistoryThe patient didnt have any history of allergy.

VIII. Mothers Pregnancy HistoryAntenatal Care: Mother checked her pregnancy routine at clinics every 3 months.Giving birth spontaneously at 38 weeks, without any complication.

IX. Birth HistoryLabor : HospitalBirth attendants: ObstetricianMode of delivery: SpontaneousGestation: 38 weeksFetal membrane: ClearInfant state: HealthyBirth weight : 2800 gramsBody length: 47 cmAccording to the mother, the baby started to cry and the baby's skin is red. No congenital defects.

X. Post-natal HistoryExamination: By doctorInfant State: Healthy

XI. History of DevelopmentPsychomotor development Smile: 2 months Slant: 4 months Prone : 4 months Sitting: 6 monthsCrawling: 8 months Standing: 8 monthsWalking: 12 monthsConclusion: normal motor development status

XII. History of EatingMothers breast milk exclusively from age 0-6 months.

XIII. Immunization HistoryCompleted Hepatitis B, BCG, Polio, and DTP vaccination.

XIV. Family HistoryAll of the family members are in a healthy state

XV. History of Hereditary DiseaseThe patients father doesnt have Hypertension nor Diabetes MellitusThe patients mother doesnt have Hypertension nor Diabetes Mellitus

XVI. Mode of ReproductionNumber of childrenAge Gender

16 years oldMale

21 years and 4 months oldFemale (Patient)

XVII. Physical ExaminationGeneral Appearance: Looks mildly ill Consciousness: Compos MentisVital Signs Pulse: 120 beats / minute, strong, full, regular The rate of breathing: 48 times / minute Body Temperature: 38.5 C

XVIII. Nutritional StatusANTHROPOMETRIC DATABody weight: 6.5 kgBody length: 63 cmWFA (Weight for Age): 15/13.4 x 100 % = 111 %HFA (Height for Age): 95/90 x 100 % = 105 %WFH (Weight for Height): 15/14 x 100 % = 107 %

XIX. Systemic Physical Examination

XX. Lab Results on April 1st 2015

XXI. Plain Abdomen X-Ray

XXII. ResumeA 1 year and 4 months old girl, came to POLRI Hospital ER at 1st April 2015, with a chief complain of vomiting. Patient vomit more than 5 times a day, filled with fluid and waste food. The patient complained of nausea, bloating, and abdominal pain since 1 day before the admission. Patient also has fever lasts from 3 days, non-continuously, with the highest temperature 40oC at night. On physical examination, she had no bowel sound on auscultation. There is distention and tenderness on palpation. She also has a high temperature that reach 38.5oC.On lab results, there is slight anemia and leukocytosis.

XXIII. Working DiagnosisIleus ParalyticReasons :a. Feverb. Nauseac. Vomitingd. No bowel sound on abdomen auscultatione. Distention and tenderness on abdomen palpation

XXIV. Differential DiagnosisIleus ObstructionAppendicitis

XXV. ManagementCefotaxime 2 x 750 mgParacetamol 5ml 3 x 1Ambroxol syrup 3 x 1 cthDomperidone 3 x 1 (0,2-0,4 mg/kgBW/day)Rontgen BNO AbdomenNothing per oralAdd NGT

XXVI. PrognosisQuo ad vitam: Dubia ad bonamQuo ad functionam: Dubia ad bonamQuo ad sanationam: Dubia ad bonam

XXVII. Follow Up

April 2nd 2015 (Lab results)Hematology : Hemoglobin11 (12-14) g/dl Leukocyte13.200 (5.000-10.000) u/l Hematocrit30 (37-43) % Thrombocyte226.000 (150.000-400.000) /ul Basophil- (0-1) % Eosinophil1(1-3) % Rod1(2-6) % Segment83(50-70) % Lymphocyte12 (20-40) % Monocyte3 (2-8) % LED60 (