CASE MANAGEMENT PRESENTATION, AND SHARING OF INFORMATION ON A NEWBORN WITH AN IMPERFORATE ANUS

TUESDAY, MARCH 21, 2006, 9:30 – 10:30 AM
DEPARTMENT OF SURGERY
CONFERENCE ROOM


HISTORY OF THE PRESENT ILLNESS:

Patient was born to a 19 year old G2P2 (2002) mother via NSD, full term at Gagalangin Health Center with an APGAR score of 8,9, with good cry and good activity. The mother claimed that she had 2 PNCU at the same health center with intake of multivitamins, no exposure to radiation, intake of teratogenic drugs and maternal illness during pregnancy.

The patient was noted to have no anal opening hence was referred to OMMC and was admitted at the Pedia ward.

FEEDING HISTORY: Breastmilk

REVIEW OF SYSTEMS:
No weight loss, no fever, no chills
No cough, no colds, no DOB
No constipation, no diarrhea
No frequency, no urgency, no oliguria

PHYSICAL EXAMINATION:
Not in cardio-respiratory distress, asleep, comfortable
CR=156 RR=51 T=36.7
SKIN Good skin turgor, (-) pallor, (-) jaundice
Head/neck Pink palpebral conj, anicteric sclerae, no NAD, no TPC, open anterior and posterior fontanel, not bulging
Chest SCE, no retractions, no lagging, clear breath sounds
Heart Adynamic precordium, NRRR, PMI at 4th ICS, LMCL, no murmurs
Abdomen Slightly distended abdomen with visible superficial veins, soft, non-tender, normo-active bowel sounds
Rectal Absent anal opening, noted a dark blue colored strand of skin on the perineal area, midline
Extremities No edema no cyanosis


ASSSESSMENT: Imperforate Anus

COURSE IN THE WARDS:
Patient underwent cut-back anoplasty for a low lying imperforate anus, placed on medications Ampicillin 75 mkd, Metronidazole 15 mkd, Gentamycin 5 mkd. Feeding was started on the 3rd POD, antibiotics completed to the 7th day, and the patient was discharged.