Pediatric Surgery Report

Sunday, January 24th 2021

Utami/Silmi/Putri/Ruli/Dipo/Alhan
 Patients Distribution

Num Identity Sex Age Diagnosis Problem Management Exp

1 Muh Ghifari M 10 yo Local Peritonitis (K56.7) due to Abdominal pain Nothing per oral Emergency
hollow viscus perforation due to IVFD Lactate Ringer , Maintenance : 1500 cc, Deficit : 1200
displaced shunt (T85.02XS) in cc, Loading : 200 cc
patient with hydrocephalus 1st 8hr : 600 + 500 – 200 cc = 900 cc/8hr = 112,5 cc/hr
(G91,9) Post 2nd 16hr : 600 + 1000 cc = 1600 cc/16hr = 100 cc/hr
Ventriculoperitoneal shunt Ceftriaxone 2 x 1 g IV
(V45.2) + Mild dehydration Metronidazole 3 x 200 mg IV
(E86) Paracetamol 3 x 300 mg IV
Planning : Exploratory laparotomy (54.11)

Neurosurgery Management : Externalization shunt

1 PATIENT

EMERGENCY PATIENT
 Muh Ghifari/M/10 years old (10-10-2010)/ BW: 20 kg
MR : 0001464635-21020269/ ADM : 24-01-21 / Emergency
Consultant : dr. Vita Indriasari, SpBA(K)
Chief complain: Abdominal pain

Patient suffered from abdominal pain since 1 day prior to admission. Abdominal pain was sharp, at lower
abdomen that felt continuously. The complain accompanied by distended abdomen at lower abdomen and fever
since 6 hours prior to admission. The patient also suffered vomiting that occured more than 10 times, containing
food leftover. No history of billous vomiting. Last bowel movement was 1 day prior to admission, soft consistency,
yellowish-coloured. There was no pain during micturition.
Patient had history of enlargement of his head and seizure since 3 months old. Since then the patient had
diagnosed with hydrocephalus and epilepsy. He had performed Ventriculoperitonel Shunt operation in Hasan
Sadikin Hospital at 3 months old. The patient routinely taking valproic acid since diagnosed with epilepsy. It has
been 2 years the patient did not brought control to neurosurgery polyclinic. Due to his complain, patient was
brought to Advent hospital and given antacid and domperidone. Because there was no improvement, he was then
brought to Hasan Sadikin Hospital for further management.
 Physical Examination

Consciousness: alertness
Pulse rate: 100 x/mnt RR: 24x/mnt T: 36,8°C
Head : sunken eyes, conjunctiva was not anemic, sclera was not icteric, wet lips and mouth mucosa
Colli : there was Ventriculoperitoneal shunt tube
Chest : symmetrical shape and movement, no retraction of intercostal and epigastric
Lungs : equal vesicular breath sound, no rhonchi, no wheezing
Heart : regular heart sound, no murmur
Abdomen :
• I : distended at lower quadrant abdomen , scar from previous operation
• A : weak bowel sound
• P : there were tenderness and muscular defense at lower quadrant abdomen
Urine output : 0,8 cc/kgBW/hr  loading  UO : 2 cc/kgBW/hr
Extremity : warm, capillary refill time < 2”
Clinical Picture
Clinical Picture
 Clinical Picture

NGT Urine output

 Laboratory Results
24-10-2020, Hasan Sadikin Hospital

• Hb : 14,4 • AST : 15
• Ht : 44,0 • ALT : 12
• WBC: 26.240 • Ur : 27
• Platelet : 366.000 • Cr : 0,80
• PT : 11,90 • Sodium : 135
• INR : 1,08 • Potassium : 4,4
• APTT : 27,70 • Albumin : 4,57
• Diff count : • CRP : 5,9
Bas/Eos/Band/Seg/Lim/Mo : 0/0/0/68/24/8 • Anti SARS-Cov-2 : Non reaktif
 Chest X-Ray
24-01-2020, Hasan Sadikin Hospital
 Abdominal X-Ray
24-01-2021, Hasan Sadikin Hospital
Working Diagnosis :
Localized Peritonitis (K56.7) due to hollow viscus perforation due to displaced shunt (T85.02XS) in patient with congenital
hydrocephalus (G91,9) Post Ventriculoperitoneal shunt (V45.2) + Epilepsy (G40.909) + Mild dehydration (E86)

Management:
• Nothing per oral
• IVFD Lactate Ringer , Maintenance : 1500 cc, Deficit : 1200 cc, Loading : 200 cc
1st 8hr : 600 + 500 – 200 cc = 900 cc/8hr = 112,5 cc/hr
2nd 16hr : 600 + 1000 cc = 1600 cc/16hr = 100 cc/hr
• Ceftriaxone 2 x 1 g IV
• Metronidazole loading 300 mg IV  maintenance 3 x 150 mg IV
• Paracetamol 3 x 300 mg IV
• Valproic acid 2x6 ml po
• Plan for : Exploratory laparotomy (54.11)

Neurosurgery :
• Plan for : Externalization shunt
THANK YOU
1 Patient

OBSERVATION PATIENT
 Mrs Siti Nurhasanah’s baby / F / 11 days old (13-01-2021) / BW : 2020 grams
MR : 0001895286 - 21030197 / ADM : 13-01-2021 / Anturium
Consultant : dr. Vita Indriasari, Sp.BA(K)
Patient hospitalized at Anturium ward with working diagnosis : Total obstruction at level duodenal due to duodenal
web without fenestrae post duodenoplasty POD 1 + Thrombocytopenia (P53) + Hypoalbuminemia (E88.0) +
Electrolyte imbalance (hyponatremia E87.1 , hypokalemia E87.6 )

At our duty time :

S : bloody vomiting, no distended abdomen, no fever
O : Consiousness: State 5, Heart rate: 175x/minute, Respiratory Rate: 40x/minute, Temperature: 37,0 °C, Spo2 99%
with oxygen 1 Lpm via nasal canule
Head: conjunctiva was anemic, sclera was not icteric, moist lips and mouth mucosa.
OGT : 15 ml, reddish
NGT transanastomotic : closed
Chest: symmetrical shape & movement, retraction of suprasternal, intercostal and epigastrium.
Lungs : equal vesicular breath sound, no rales , no wheezing
Heart : regular heart sound, no murmur
 Mrs Siti Nurhasanah’s baby / F / 11 days old (13-01-2021) / BW : 2020 grams
MR : 0001895286 - 21030197 / ADM : 13-01-2021 / Anturium
Consultant : dr. Vita Indriasari, Sp.BA(K)
Abdomen :
I : flat , no visible bowel contour, no visible peristaltic wave at abdominal wall, no hyperemic, operation wound :
intact, no dehiscence
A : weak bowel sound
P : soft in palpation, no muscular defense

Urine output : 2 cc/kgbw/hour

Extremities : warm, capillary refill time < 2“

Laboratorium (24-01-21):
Hb/Ht/WBC/Platelet : 11,3/31,4/21.020/7.000
Alb: 1,88
Na/K : 133/3,1
Clinical Picture
Clinical Picture
 Mrs Siti Nurhasanah’s baby / F / 11 days old (13-01-2021) / BW : 2020 grams
MR : 0001895286 - 21030197 / ADM : 13-01-2021 / Anturium
Consultant : dr. Vita Indriasari, Sp.BA(K)
A : Total obstruction at level duodenal due to duodenal web without fenestrae post duodenoplasty POD 2 + Sepsis
(A41.9) + Upper Gastrointestinal bleeding (K92.2) due to suspect Disseminated intravascular coagulation (D65) +
Thrombocytopenia (P53) + Hypoalbuminemia (E88.0) + Electrolyte imbalance (hyponatremia E87.1 , hypokalemia
E87.6)

P:
- Nothing per oral
- NGT decompression with NG tube no 10 Fr
- Oxygen 1 Lpm via nasal canule
- Monitoring input-output
- IVFD TPN 13,15 cc/hour (D40% 19 cc, 10% 154 cc, Nacl 3% 31 cc, Kcl7.4% 2 cc, Ca glu 4 cc,Aminosteril 6% 105 cc)
- Cefotaxime 2 x 100 mg IV
- Paracetamol 3 x 40 mg IV
- Metoclorpramide 3 x 0,19 mg IV
- Omeprazole 2 x 2 mg IV
- Vitamin K 5 mg subcutaneous
- PRC transfusion 20 cc, FFP transfusion 20 cc, TC transfusion 20 cc, Albumin transfusion 10 cc
- Plan for Intensive Room room not available
 Observation Table
Date/Time S O A P

24-01-2021 Bloody Consiousness: State 5, Heart rate: 175x/minute, Total obstruction at level - Nothing per oral
12.00 vomiting Respiratory Rate: 40x/minute, Temperature: 37,0 °C, duodenal due to duodenal - NGT decompression with NG tube no 10 Fr
Spo2 99% with oxygen 1 Lpm via nasal canule web without fenestrae post - Oxygen 1 Lpm via nasal canule
Head: conjunctiva was anemic, sclera was not icteric, duodenoplasty POD 1 + - Monitoring input-output
moist lips and mouth mucosa. Sepsis (A41.9) + Upper - IVFD TPN 13,15 cc/hour (D40% 19 cc, 10% 154 cc, Nacl 3% 31
OGT : 15 ml, reddish Gastrointestinal bleeding cc, Kcl7.4% 2 cc, Ca glu 4 cc,Aminosteril 6% 105 cc)
Chest: symmetrical shape & movement, retraction of (K92.2) due to suspect - Cefotaxime 2 x 100 mg IV
suprasternal, intercostal and epigastrium. Disseminated intravascular -Paracetamol 3 x 40 mg IV
Lungs : equal vesicular breath sound, no rales , no coagulation (D65) + -Metoclorpramide 3 x 0,19 mg IV
wheezing Thrombocytopenia (P53) + -Omeprazole 2 x 2 mg IV
Heart : regular heart sound, no murmur Hypoalbuminemia (E88.0) + -Vitamin K 5 mg subcutaneous
Abdomen : Electrolyte imbalance -PRC transfusion 20 cc, FFP transfusion 20 cc, TC transfusion 20
I : flat , no visible bowel contour, no visible peristaltic (hyponatremia E87.1 , cc, Albumin transfusion 10 cc
wave at abdominal wall, no hyperemic, operation hypokalemia E87.6)
wound : intact, no dehiscence
A : weak bowel sound
P : soft in palpation, no muscular defense

Urine output : 2 cc/kgbw/hour

Extremities : warm, capillary refill time < 2“
Laboratorium (24-01-21):
Hb/Ht/WBC/Platelet : 11,3/31,4/21.020/7.000
Alb: 1,88
Na/K : 133/3,1
 Observation Table
Date/Time S O A P

24-01-2021 Bloody Consiousness: State 5, Heart rate: 168x/minute, Total obstruction at level - Nothing per oral
16.30 vomiting Respiratory Rate: 40x/minute, Temperature: 36,9 °C, duodenal due to duodenal - NGT decompression with NG tube no 10 Fr
Spo2 99% with oxygen 1 Lpm via nasal canule web without fenestrae post - Oxygen 1 Lpm via nasal canule
Head: conjunctiva was anemic, sclera was not icteric, duodenoplasty POD 1 + - Monitoring input-output
moist lips and mouth mucosa. Sepsis (A41.9) + Upper - IVFD TPN 13,15 cc/hour (D40% 19 cc, 10% 154 cc, Nacl 3% 31
OGT : 3 ml, reddish Gastrointestinal bleeding cc, Kcl7.4% 2 cc, Ca glu 4 cc,Aminosteril 6% 105 cc)
Chest: symmetrical shape & movement, retraction of (K92.2) due to suspect - Cefotaxime 2 x 100 mg IV
suprasternal, intercostal and epigastrium. Disseminated intravascular -Paracetamol 3 x 40 mg IV
Lungs : equal vesicular breath sound, no rales , no coagulation (D65) + -Metoclorpramide 3 x 0,19 mg IV
wheezing Thrombocytopenia (P53) + -Omeprazole 2 x 2 mg IV
Heart : regular heart sound, no murmur Hypoalbuminemia (E88.0) + -Vitamin K 5 mg subcutaneous
Abdomen : Electrolyte imbalance -PRC transfusion 20 cc, FFP transfusion 20 cc, TC transfusion 20
I : flat , no visible bowel contour, no visible peristaltic (hyponatremia E87.1 , cc, Albumin transfusion 10 cc
wave at abdominal wall, no hyperemic, operation hypokalemia E87.6)
wound : intact, no dehiscence
A : weak bowel sound
P : soft in palpation, no muscular defense

Urine output : 1,8 cc/kgbw/hour

Extremities : warm, capillary refill time < 2“
 Observation Table
Date/Time S O A P

24-01-2021 Bloody Consiousness: State 5, Heart rate: 168x/minute, Total obstruction at level - Nothing per oral
17.30 vomiting Respiratory Rate: 40x/minute, Temperature: 36,9 °C, duodenal due to duodenal - NGT decompression with NG tube no 10 Fr
Spo2 99% with oxygen 1 Lpm via nasal canule web without fenestrae post - Oxygen 1 Lpm via nasal canule
Head: conjunctiva was anemic, sclera was not icteric, duodenoplasty POD 1 + - Monitoring input-output
moist lips and mouth mucosa. Sepsis (A41.9) + Upper - IVFD TPN 13,15 cc/hour (D40% 19 cc, 10% 154 cc, Nacl 3% 31
OGT : 3 ml, reddish Gastrointestinal bleeding cc, Kcl7.4% 2 cc, Ca glu 4 cc,Aminosteril 6% 105 cc)
Chest: symmetrical shape & movement, retraction of (K92.2) due to suspect - Cefotaxime 2 x 100 mg IV
suprasternal, intercostal and epigastrium. Disseminated intravascular -Paracetamol 3 x 40 mg IV
Lungs : equal vesicular breath sound, no rales , no coagulation (D65) + -Metoclorpramide 3 x 0,19 mg IV
wheezing Thrombocytopenia (P53) + -Omeprazole 2 x 2 mg IV
Heart : regular heart sound, no murmur Hypoalbuminemia (E88.0) + -Vitamin K 5 mg subcutaneous
Abdomen : Electrolyte imbalance -PRC transfusion 20 cc, FFP transfusion 20 cc, TC transfusion 20
I : flat , no visible bowel contour, no visible peristaltic (hyponatremia E87.1 , cc, Albumin transfusion 10 cc
wave at abdominal wall, no hyperemic, operation hypokalemia E87.6)
wound : intact, no dehiscence
A : weak bowel sound
P : soft in palpation, no muscular defense

Urine output : 1,8 cc/kgbw/hour

Extremities : warm, capillary refill time < 2“
 Observation Table

Date/Time S O A P
09-01-2021 Distended Abdomen Consiousness: State 4, Heart rate: Diffuse peritonitis (K65) - Nothing per oral
15.00 138x/minute, Respiratory Rate: 42x/minute, due to Hollow viscus - NGT decompression with NG tube no 10 Fr
Temperature: 36,7 °C, Spo2 97% with Neo T perforation (K63.1) + - NeoT 12 lpm peep 7 FiO2 100%
PEEP 7 cmH20 FiO2 100% 12 Lpm Septic shock (R65.21) + - Monitoring input-output
Head: conjunctiva was not anemic, sclera Sepsis (A41.9) + - IVFD TPN 11,5 cc/hour (D40% 19,9 cc, 10% 218.8 cc, Nacl
was not icteric, moist lips and mouth Thrombocytopenia (P53) + 3% 33 cc, Kcl7.4% 3,3 cc, Aminosteril 6% 55 cc)
mucosa. Hypoalbuminemia (E88.0) - Dopamin 0,5 mcg/kgbw/hr
OGT : 10 ml, reddish + post needle - Plan for Exploratory Laparotomy (54.11)
Chest: symmetrical shape & movement, decompression POD 8 - Plan for Intensive Room room not available
retraction of suprasternal, intercostal and
epigastrium. - Informed consent to the parents about baby’s condition
Lungs : equal vesicular breath sound, no
rales , no wheezing
Heart : regular heart sound, no murmur
Abdomen :
I : distended, vein ectasia +, no visible
bowel contour, no visible peristaltic wave at
abdominal wall, hyperemic +
A : weak bowel sound
P : tense in palpation
Needle Decompression: 10 ml greenish
Urine output : 1,1 cc/kgbw/hour
Extremities : warm, capillary refill time < 2“
THANK YOU