Case Report, Monday, April 7th 2014

Team on duty :

•dr. Andria Saputra•dr. M. Nazir Tambunan•dr. Rynaldi Andriansya•dr. Sumrahadi Manurung•dr. Khalikul•dr. Jauhari Deslo Angkasa Wijaya•dr. Muharriansyah

2

/961912

No Distribution of surgery patient Room Total

1 Emergency room patient 6 Patients

2 Hospitalize 1 Patients

3 Out of clinic 5 Patients

4 Refuse medical advice -

5 Passed away Jeumpa 3

Nur Ainun/46 yo/F/Dx. Ca. Mammae Sinistra End Stage + Ulcus Decubitus + Multiple Site Bone Metastase + Anemia/ POD 6/COD : End Stage

6 Hospitalize room Jempa 1 28/28 bed

Jempa 2 28/28 bed

Jempa 3 28/28 bed

Jempa 4 28/28 bed

3

No Distribution of surgery patient Room Total

ICU 3 Patients

HCU 2 Patients

NICU 4 Patients

PICU 2 Patients

4

ICU 1. Azhari Ilyas/ M/ 23 yo/Dx. Contusion ICH temporal grade III + SDH Temporal/Tx. Craniotomy Evacuated/POD 2

2. Muchtar Ubit/M/62 yo/Dx. Stroke Haemorraghic + ICH a/r Fronto Temporal + Hydrochepalus/Tx. Craniotomy Evacuated ICH/POD 6

3. Elli Fitria/ F/28 yo/Dx. Effusion Pleura Dextra + Pneumonia/Tx. Post WSD/POD 4

5

HCU 1. Ismanidar/F/30 yo/Dx. Perforation Jejunum + Resection Anastomosis with Stapler + Haematothoraks dextra/Tx. Laparatomy Eksploration/POD 7

2. Khairil Anwar/M/46 yo/Dx. Chest Pain + Dyspneu/Tx. Angiography/POD 1

PICU 1. Laili Huda Haki/ 13 yo/ F/Dx. Post Laparotomy Eksploration + Adhesiolisis + Ileal Resection + Redo Iileostomy ec Ileal Anastomose Leakage Post Redo Ileostomy + Primary Suture Ileal Perforation ec Abdominal Burst due to Appendix Perforation/Tx. Debridement/POD 3

2. M. Mirza/M/7 yo/Dx. Combutio 30% Grade II-III with Inhalation Trauma + Compartment Syndrome/Tx. Debridement + Fasciotomi/POD 2

NICU 1. By Ida khairuna/G/9 do/Dx. Hydrochepalus Congenital/AD 6

2. By Yenita /G/11 do /Dx. Hydrocephalus/Tx. Vp Shunt/POD 5

3. By Tristiana/M/17 do / Re-laparatomy exploration + resection anastomose + ileo ileal and repair perforation jejunum / POD 11

4. By Fitriani/G/ 8 do /Dx. Malformation Anorectal High Level Without Fistel/Tx. Colostomy Divided/POD 5

Patient identity

• Name : Dika Mauliza• Age : 15 years old• Sex : Boy• Address : Kp Mulia, Kec. Syiah Kuala,

Banda Aceh• MR : 99 75 13• Driving License : (-)• Phone number : 081362611337• Patient came at : 06.36 PM

Chief complaintDecrease of consciousness

Patient illness HistoryThe patient came to Zainoel Abidin emergency room with decrease of consciousness for 1 hour. The complaint started when the patient was riding motorcycle without helmet and suddenly strucked by another motorcycle from beside of him. There was history of vomiting.. There was no trauma at the other part of body..

Physical examination

Primary Survey• A: Clear• B: Spontaneous, RR: 20 breaths/ minute• C: BP : 130/80 mmHg Pulse: 70 beats/minute• D: GCS: E3 M6 V4 GCS 13, isochoric pupil Ø

3 mm/ 3 mm, light reflex (+/+)

L/S at the right temporal regionL : swelling (+), wound(-)

Secondary Survey There was no trauma at other part body

Assessments: Moderate head injury

Management

• Stop oral intake• Head up 300

• Oxygen 2 litre / minute via canule• IVFD NaCl 0,9% 20 drips/minute • Inj. Ceftriaxone 1 gr• Inj. Metamizol sodium 1 gr• Laboratory examination • Radiology examination

Laboratory result

• Hb : 15,5 gr/dl • White blood count : 16.400/ul• Platelet : 290.000 /ul• Ht : 46 %• CT : 6 minute• BT : 2 minute • Blood glucose ad random : 133 mg/dl

Radiology result

Head CT-Scan :• There was SCALP hematoma at the left ocipital

region• There was no fracture at the bone window• Sulcus and gyrus was narrow• There was hyperdense biconvex area at the right

temporal base region EDH• Ventricle and cysterna system was narrow• There was no midline shift

Diagnose: Moderate head injury + EDH at the right temporal base region

Consult to Neurosurgery Division : Craniotomy evacuation EDH emergency

Operative report• Patient in supine position, head up 30o and turn to the left

with general anesthesia. • Performed aseptic and antiseptic procedure • Performed reverse question mark incision until bone • Performed 3 Burr hole, bone was sawed with gigly and

pulled out • Identified EDH with thick 3 cm• Performed dura hit stiches and evacuated the EDH 30 cc • Bleeding control • Bone was return • Performed one tube drain• Closure the wound by primary suture

Post Operative DiagnosedModerate head injury (ICD 10 CM S09.9) + EDH at the right temporal base region (ICD 10 CM S06.4)

Follow UpDate S O A P

11/4/2014POD IV

Pain (-)

VS/BP : 110/ 70 mmHgPulse: 88 beats/mnt RR: 20 breaths/minute GCS : E4 M6 V5 pupil isochoricTemp 36,7oC

Moderate head injury (ICD 10 CM S09.9) + EDH at the right temporal base region (ICD 10 CM S06.4)

Diet 1800 Kcal Head up 30o

IVFD NaCl 0,9% 20 drips/minutesCeftriaxone inj 1g/12 hoursMetamizol sodium inj 1 g/8 hours

Patient identity

• Name : Farid Wajdi • Age : 34 years old• Sex : Male• Address : Blang Oi, Kec. Meuraxa,

Banda Aceh• MR : 99 74 93• Phone Number : 085260875584• Patient came at : 02.01 PM

Chief complaintPain at the right lower abdomen

Patient illnes History

Patient came to Zainoel Abidin emergency room with a chief complaint pain at the right lower abdomen since 6 hours ago. Initially, patient felt pain at epigastric region and then pain was remain at the lower right abdomen. History of fever and vomiting was present.

Physical examination• Vital sign :– Blood Pressure : 110/70 mmHg– Pulse : 100 beats/min– Respiratory rates : 22 breaths/min– Body temperature: 36,7 oC

• L/S at the right lower abdominal region :– I : Symmetrical, distension (-)– A: Bowel sound (+)– P: Pain at McBurney sign (+)– P: Thympani (+)

Digital rectal examination • Tonus Spinchter ani: Tight• Rectal Ampulla : Faeces (+)• Rectal Mucous : Smooth• Pain : (+)• Glove : Faeces(+)

Assessments: Acute Appendicitis

Management

• Stop oral intake• IVFD RL 20 drips / minute• Inj. Ceftriaxone 1 gr• Inj. Ketorolac 30 mg• Laboratory examination

Diagnosed Acute Appendicitis

Consult to pediatric surgery divisionAppendectomy emergency

Operative report• Patient in supine position with general anasthesia• A and Antiseptic procedure and then drapping procedure• Performed Grid iron incision• Incision was deepened layer by layer until found peritoneum• Direct exploration to caecum• Identified caecum, appendix antecaecal, erectil, oedem, length 7

cm and without perforation• Appendix was release from mesoapendix with antegrade and

bleeding controlled.• Performed appendectomy and double ligation sutured• Operation area irrigated with normal saline until surely clean• Operation wound closed by primary suture

Post Operative Diagnosed Acute appendicitis (ICD 10 CM K35.2)

Follow UpDate S O A P

10/4/2014POD III

Pain (-) Vital Sign :General condition: goodBP : 120/80 mmHgRR : 18 breaths/mntPulse : 78 beats/mntL/S at the right lower abdominal region :I : SymmetricalA: Bowel sound (+)P: Pain (-)P: Tympani (+)

Acute appendicitis (ICD 10 CM K35.2)

Outclinic patient.