A/D Irma Novie Sari/F/24 hours

Chief complaint : abdomen distensionHistory taking :This happened since she was born 18 hours before hospital admission, delivered by SC a/i plasenta previa+polihidramnion. History of meconium excretion (-). The abdomen getting larger when admitted. Vomitting (+), fever (-) .

Present StateAwareness : loudly cryingHeart rate : 108 x/mRespiratory rate : 34 x/mTemperature : 36,2 CWeight : 2,6 kgHeight : 44 cm

Localize state.Eyes : conjuctiva palpebra inferior anemic (-/-)Ear / nose / mouth : no abnormalityNeck : no abnormalityThorax : no abnormality

Abdomen :Inspection: simetric large (+), visible peristaltic (-)Palpation: distension (+), muscular rigidity (-)Percussion: timphanyAuscultasion: peristaltic (++)

Genitalia : female, no abnormalityExtremity : no abnormality

DRE: perineum: usualanal spinchter: thightmukosa recti: smoothampula recti: collapsedhand glove : Meconium (-), mucous (-), blood (-)

Laboratory finding :

Hb : 10,8gr/dlHt : 35,1 %Wbc : 23.000 ulPlt : 180.000 ulGlucose : 70 mg/dl

PT/ INR/APT: 14,9/1,25/33,7

AGDAPH : 7,089PCO2 : 64,2PO2 : 143,2TCO2 : 21,6HCO3 : 19,6BE : - 10,4O2 sat: 97,7

We Diagnose with : Susp atresia ileum

We performed in ER : IVFD Dextrose 5 %+NaCL 0,0225 % (4:1) 6 gtt micro/minuteNGT DecompressionCatheterAntibiotic

Thank you