Ch. Hani/ 2 y.o.

/ 1-42-45-11/ admitted
at 07.00 pm, 3rd April 2019

Chief Complain: Vomiting

History :
Patient referral from Dr. Murjani Sampit Hospital with a diagnosis of obstructive ileus treated for 2 days. At first the
patient complains of vomiting, vomit 4 times, vomiting yellowish content. Vomiting when the patient drinks or eats.
Vomiting accompanied by bloating. Defecat liquid stool (+) more than 4 times, but reduced by 2-3 days. Abdominal pain
(+), the patient cannot indicate the location of the pain. Patients cry if pain. Patients had seizures of approximately 3
days ago fever (-), whole body seizures, seizures of approximately 5 minutes, patients had also previously had seizures at
the age of 9 months and 1 year 8 months but were preceded by fever. Patients also had lumps on the left and right
genitalia, lumps is reducible, arise when the patient cries or strains. According to the family, the child complains of pain if
the lump is pressed.
Pregnancy history: pregnant second child, twins, non-routine ante natal care history (2 times), taking iron
suplementation (+) regularly, drinking herbal medicine (+) trimester 3. Massage (+) gestational age> 7 months for 3 times
Childbirth: born normal, gemeli, helped by a midwife, immediately crying, cyanosis (-), BBL: 2000/2000 gr, born aterm.
Postnatal history: Breast milk aged 0-3 months, after that drink formulas milk, routine immunization (+), development
and growth are not disturbed (patients can walk)
 Vital Sign
• HR : 131 bpm (regular and strong pulse)
• RR : 30 tpm
• T : 36,8o C
• CRT : <3 second
• SpO2 : 99% without O2 supplementary
Physical Examination
Head/Neck •pale conjungtiva (-/-), sclera icteric (-/-), mass (-), torticalis (-)

• I : symmetric respiratory movement, retraction(-)

• P : symmetric VF
Chest • P : sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

• I : distention (+), mass (-) darm contour (-)

• A : Increased bowel sound, metallic sound (-)
Abdomen • P : Tympanic sound
• P : tenderness (-) rebound tenderness (-), muscular rigidity (-) left inguinal lump
(+)

Extremities • warm (+), edema (-), pale (-)

Physical Examination

Anomaly Screening :

V : vertebrae anomaly (-)

A : malformation anorectal (-)
C : cardiac defect (-)
TE : trachea-esophageal fistula (-)
R : renal anomali (-)
L : Limb deformity (-)
Clinical Pictures
X - Ray
USG Abdomen
Kesan:

1. Usus melebar dengan peristaltic menuruntak

ditemukan gambaran invaginasi

2. Kantung kemih melebar terisi urin yang

menyebabkan kalises ginjal kanan kiri melebar.
 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 12,0 12,00-16,00 g/dl
Leukosit 7,9 4,0-10,5 ribu/ul
Eritrosit 4,58 3,90-5,50 juta/ul
Hematokrit 35,1 37,00-47,00 vol%
Trombosit 245 150-450 ribu/ul
RDW-CV 13,9 11,5-14,7 %
MCV 76,6 80,0-97,0 fl
MCH 26,2 27,0-32,0 pg
MCHC 34,2 32,0- 38,0 %
Gran% 38,3 50.0 – 81,0 %
Limfosit% 51,3 20,0 – 40,0 %
Gran 3,01 2,50 – 7,00 ribu/ul
Limfosit 4,04 1,25 – 4,00 ribu/ul
Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
PT 9,8 9,9-13,5 detik
INR 0,96
APTT 29,3 22,2-37,0 detik
GDS 101 <200
SGOT 68 0-46 U/l
SGPT 39 0-45 U/l
Ureum 6 10-50 mg/dl
Creatinin 0,30 0,7-1,4 mg/dl
Natrium 139 135-146 mmol/l
Kalium 4,5 3,4-5,4 mmol/l
Chlorida 103 95-100 mmol/l
 Diagnosis
HIL Incarserata Sx + Obs Seizure
 Management
Treatment in ER: Consult to Pediatric surgery:
IVFD D5 ½ NS 32 cc/hour Pro Hernioraphy
Inj. Paracetamol 80gr Wash out with warm Nacl 0,9%
NGT (+)
Urin Cateter
Rectal tube (+)
Diazepam rectal 5mg
Tredelenburg position
Consult Pediatric