4 okt 2014

Morning Report Saturday, October 4th, 2014

RSUDZA

Team on duty

dr. Maria Meildi (Chief)

dr. Joko Siswanto (Coordinator)

dr. Haji Ifradin Pinim (Case report)dr. Raja Raharja MP (Medical Report)dr. M. Andri Mulia ( Medical

Report)dr. Nasrul Haidi ( Medical

Report) dr. Andri feisal Nst

(Documentation)dr. Bobbi HE Fermi (Documentation)

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No Distribution of surgery patient Room Total1 Emergency room patient Patients2 Hospitalize Patients3 Out of clinic Patients4 Refuse medical advice Patient5 Passed away

6 Hospitalize room Jeumpa 1 27/28 bedJeumpa 2 26/28 bedJeumpa 3 25/28 bedJeumpa 4 26/28 bed

PJT 23/26 bed

ICU 6 PatientsHCU 3 PatientsICCU 0 PatientsPICU 2 PatientsNICU 6 Patients

3

ICU ADULT • Zainal Abidin/M/70 yo/dx: Post Craniotomy due to Intracranial Hemorrhage/POD X

• Sofyan/M/56 yo/dx: Post VP-Shunt due to Intraventricular Hemorrhage/POD VII

• Agung perdana/M/27 yo/dx : post repair TACD/POD 0• Nurhayati/F/39yo/Post Craniotomy Evakuasi Tumor/POD II• Razali /M/19yo/Post Craniotomy due to EDH/POD 0• Syamsiah/F/69 yo/dx: Post Laparotomy Exploratory due to General

Pritonitis due to Gaster Perforation/POD V

HCU • Noval/M/9yo/post debridement due to crush injury ar antebrachii Sinistra/POD II

• Zulkarnaen/M/44yo/ post vp-shunt due ti hidrochephalus non comunicant POD 0

• Abasyiah/F/62yo/ post wide eksisi due to SCC regio labialis inferior

06/07/14

NICU • By. Al Fatih/M/4 do/Dx: Post Minimal PSA due to Malformation Anorectal + Hypospadia Midshaft Type + Down Syndrome/POD VIII

• Muhammad Rizky faisal/M/17 do/Dx: Intra-Abdominal Mass + Bilateral Hernia Inguinalis/POD II

• By. Nurainun/M/27do/post duodenus duodenostomy due to anulare pancreas/POD VII

• By . Ratna dewi 1/M/1do/post minimal PSA due to malformasi anorectal + fistula proksimal/POD 0

• By Ratna dewi 2/M/1do/malformasi anorectal without fistel/ AD 1• By jumiatun /M/14d0/ post duodenos duodenostomy due to

atresia duodenum /POD

PICU • M. Ikhsan/6 yo/M/dx: Post VP-Shunt due to Hydrocephalus/AD 13/POD XIV

• Muhammad Fajri/6 mo/Post Op Colostomy Closure/POD II

Patient identity• Name : Ervan• Age : 36 years old• Sex : Male• Address : Paloh lada, Kec.Dewantara,

Kab.Aceh utara• Phone : 085277125470• MR : 1021431• Patient came : 02.15 PM• Driving Liscence : (-)

Chief complaint• Headache after trauma Patient illnes History• The patient was referred from Pt.Arun distric hospital came to

RSUDZA emergency room with a chief complaint headache after trauma for 2 days ago. Patient was riding motorcycle withouth helmet suddenly strucked by motorcycle from left side.He felt down to the aspalt. History of decrease of unconciousness (-).History of nausea and vomiting (-).Head Ct Scan : ICH at the bifrontal region and EDH at the left temporal region

Physical examination• A: Clear• B: Spontaneous, RR: 20 breaths• C: Blood pressure 130/80 mmHg. Pulse: 90 beats/minute• D: GCS 10 (E4 V(afasia) M6 ) ; isochoric pupil (Right 3 mm,Left 3 mm) • no lateralization, Light reflex (+/+) Secondary survey : • Head and neck

– Look : sweeling (-)l– Feel : pain (-)

• Thorax Normal – I : simetrically– P: Stem fremitus (+/+)– P: sonor (+/+)– A: vesicular (+/+)

• Abdominal Normal

– I : simetrically– A: peristaltic (+) – P: Pain (+), muscular rigidity (-)– P: tympani (+)

Assessments: • Mild head injury

Management• Head up 30°• IVFD Nacl 0,9% 10 drips/minutes• VTx BBXRR/1000- 6x60x18/1000-O2 6 l/I via nasal canul • Inj.Ceftriaxone 1 gr • Inj. Ketorolac 30 mg• Routine blood laboratory examination • Radiology examination

Laboratory result• Hb : 11,5 gr/dl • White blood count : 17.900/ul• Platelet : 326.000 /ul• Ht : 34 %• CT : 7 minute• BT : 2 minute• Blood Glucose Ad Random: 114 mg/dl•

Radiology examinationHead CT-Scan:• SCALP hematoma at the right fronto temporal region• There was no fracture • There was hiperdens area at the left temporal region-Minimally

EDH• There was hiperdens area at the bifrontal regionICH• Ventricle and cisterna system was narrow• Sulcus and gyrus was narrow.• No midline shift •

Diagnose 1. Mild head injury 2. ICH at the bifrontal region3. EDH at the left temporal4. Edema cerebri

Consult to Neurosurgery Division : • Hospitalize• Conservative theraphy evaluation of gcs• Evaluation Head CT Scan 3 days later

Follow up

Date S O A P8-10-2014Ad IV

Pain (-) VS/: general condition : goodGCS : E4 M6 V(afasia)BP : 120/90mmHgPulse : 88 beats/mntRR : 20 breaths/mnt

1. Mild head injury

2. EDH at the left temporal region

3. ICH at the bifrontal region

4. Edema Cerebri

IVFD NaCl 0,9% 10 drips/mntCeftriaxone Inj 1 gr/12 hrKetolorac Inj 30mg /8 hr

Patient identity• Name : Heri• Age : 26 years old• Sex : Male• Address : Saree, Kec.Saree,.Kab.Aceh Besar• MR : 1021429• Phone : 085373220460• Driving license : (-)• Patient came at : 01.00PM•

Chief complaint : • Pain at the thoracoabdominal region

Present illness history:• Patient was referred from publich health Seulemum to RSUDZA

emergency room with a chief complaint pain at the thoracoabdominal region after trauma for 1 hour ago. Initially, patient was riding tricycle without helmet and suddenly the tricycle strucked with a car (l300) from beside him . He fell to the street and young brother of the him dead at the street.. History of nausea and vomited (-). History of decrease of consciousness(-).

Physical examination : Primary Survey • Airway : Clear • Breathing : Spontaneous, 20 breaths/min,

Trachea in normal limit Increase of JVP (-)

Thorax examination

Right hemithorax Left hemithorax

Inspection Symmetrical, exoriated at the left hemitorax

Palpation Steam fremitus (+) Steam fremitus (+)

Percussion Sonor Sonor

Auscultation Vesicular (+) Vesicular (+)

Circulation : Blood Pressure: 110/80 mmHg, Pulse: 80 beats/minDisability : GCS 15E4M6V5, isocoric pupil 3mm/3mm

L/S at the labialis superior region• I : excoriated wound (+) size 1x1cm

L/S at the left wrish joint• I : Excoriated wound (-),Deformity (+),swelling(+)• Feel : Pain (+),NVD (-)• Move : ROM Limited

L/S at the right thigh• I : Lacerated wound (-) ,Deformity (+),swelling(+)• Feel : Pain (+),NVD (-)• Move : ROM Limited•

L/S at the left thigh• I : Lacerated wound (-) ,Deformity (-),swelling(-)• Feel : Pain (+),NVD (-)• Move : ROM Limited L/S at the left genu• I : Lacerated wound (-) ,Deformity (-),swelling(-)• Feel : Pain (+),NVD (-)• Move : ROM Limited

L/s at the left lower extremity• I : Excoriated wound (+) size 2x1cm,Deformity (+),swelling(+)• Feel : Pain (+),NVD (-)• Move : ROM Limited L/S at the abdominal region :• I : distension (-), excoriated wound at the right (+) • A : bowel sound (+) • P : pain (-), musculaire rigidity (-)• P : tymphani (+)

Digital rectal examination:• sphincter ani : tight• mucosa : smooth• ampula recti : empty

pain at all region : (-) • Glove : stool (+), blood

(-), secret (-)

Secondary survey : • Head and neck

– Look : Excoriated wound at the superior lips (+) • Thorax

– I : simetrically, excoriated wound (+)– P: crepitation (-)– P: sonor (+/+)– A: vesicular (+/+)

L/S at the left wrish joint• I : Excoriated wound (-),Deformity (+),swelling(+)

L/S at the right thigh• I : Lacerated wound (-) ,Deformity (+),swelling(+)

L/S at the left thigh• I : Lacerated wound (-) ,Deformity (-),swelling(-)

L/S at the left genu• I : Lacerated wound (-) ,Deformity (-),swelling(-)

L/s at the left lower extremity• I : Excoriated wound (+) size 2x1cm,Deformity

(+),swelling(+) • Abdominal

– I : simetrically, excoriated wound (+) ,hematom (-)– P: Pain (+), muscular rigidity (-)– P: tympani (+) – A: peristaltic (+)

Assesment: • Blunt Thoracoabdominal injury with stable

hemodynamic • Suspect. Close fracture at the left forearm• Suspect. Close fracture at the right thigh• Open fracture at the left lower extremity

Management :• IVFD RL 20 drips/min• Immobilization• VTx BBXRR/1000- 6x60x20/1000-O2 7 l/I via nasal canul • Inj. Ceftriaxon 1 gr• Inj. Ketorolac 30 mg• Inj Tetagam 250 IU• Urinary Catheter •

Time Blood pressure (mmHg),pulse (beats/minute)

Urine (Cc)

02.00 120/90mmHg, 70 beats/minutes 70cc





07.00 120/70mmHg, 80 beats /minutes 70cc




•Laboratory examination•Radiology examination

Laboratory result• Hb : 10,4 gr/dl• WBC : 21,000 /ul• Platelets : 218.000 /ul• Ht : 28 %• CT : 8 min• BT : 2 min• Blood glucose ad random : 373 mg/dl•

Radiology result• Thorak AP: • In normal limit Left ante brachii AP/Lat• There was fracture distal radius Right femur AP/Lat• There was fracture middle third of femur Left cruris Ap/Lat• There was fracture upper third tibia and fibula FAST :• There was no free fluid

Diagnosed1. Blunt Thoracoabdominal injury with stable hemodynamic 2. fracture at the lower third of the left radius3. fracture at the middle third of the right femur4. Open fracture at the upper third of the left tibia and fibula• sult to orthopaedic surgery division• - perfomed debdridement + Backslab

Consult to digestive surgery• Conservative teraphy

Operative report• Patient in supine position with general anesthesia • Performed aseptic and antiseptic • Performed debridement with NaCl 0,9%, peroxide

3% + Povidone iodine 10%• Performed refreshing the edge of wound • Wound rinse with NaCl 0,9% • Wound operation close by primary suture • Performed back slab

Post operative Diagnosed1. Blunt Thoracoabdominal injury with stable

hemodynamic 2. fracture at the lower third of the left radius3. fracture at the middle third of the right femur4. open fracture at the upper third of the left

tibia and fibula

Follow upDate S O A P

8-10-14POD III

Pain (-) Consciousness : Compos MentisBP:100/70Pulse : 100 x/menitRR: 26 x/menitTemperatur : 36,8 0CUrine Abdominal region :L/S at the abdominal region :

I: distension (-), excoriated wound at the left (+) A : bowel sound (+) P

: pain (-) musculaire rigidity (-)P: tymphani (+):

1. Blunt Thoracoabdominal injury with stable hemodynamic

2. fracture at the lower third of the left radius

3. fracture at the middle third of the right femur

4. fracture at the upper third of the left tibia and fibula

Post debridement

IVFD RL 20 drips/minInj. Cefazoline 1 grInj. Ketorolac 30 mg

Patient Identity • Name : Juan mahfuzar• Age : 29 years old• Sex : Male• Address : Lam lagang Kec.Bandar raya Kota

Banda Aceh• MR : 1021427• Phone : 08126900428• License : (+)• Patient came : at 00.30 AM

Chief Complaint: • Pain and difficult to move of the left lower extremity Present illness history • The patient was referred from Fakinah distric hospital came

to RSUDZA emergency room with a chief complaint pain and difficult to move of the left lower extremity for 1 hours ago. Initially, the patient was riding a motorcycle with helmet and suddenly strucked with tricycle from beside him. There was no trauma at another part of body. There was no history of unconsciousness, nausea and vomiting.

Physical examination • Primary Survey • Air Way : clear • Breathing : Spontaneous, 20 breaths/min • Circulation : Blood pressure : 130/70 mmHg, Heart rate 82

beats/min• Disability : GCS E4M6V5 = 15,isochoric pupil (3mm/3mm).•L/S at the Right shoulder• Look: Swelling (+), deformity (+), wound (-). • Fell : Pain (+), NVD (-)• Move : ROM limited L/S at the left thigh

Look : Swelling (+), deformity (+), wound (+). • Fell : Pain (+), NVD (-)• Move : ROM limited

L/S at the left lower extremity• Look: Swelling (+), deformity (+), wound (+)

size 2x1cm. • Fell : Pain (+), NVD (-)• Move : ROM limited

Secondary survey : • Head and neck

– Look : sweeling (-)– Feel : pain (-)

• Thorax

– I : simetrically– P: Stem fremitus (+/+)– P: sonor (+/+)– A: vesicular (+/+)

• At the right soulder

– Look : Swelling (+), deformity (+), wound (-). – Fell : Pain (+), NVD (-)– Move : ROM limited

Abdominal Normal – I : simetrically – A: peristaltic (+)– P: Pain (+), muscular rigidity (-)– P: tympani (+)

L/S at the left thigh• Look: Swelling (+), deformity (+), wound (+). • Fell : Pain (+), NVD (-)• Move : ROM limited L/S at the left lower extremity• Look: Swelling (+), deformity (+), wound (+) size 1x1cm. • Fell : Pain (+), NVD (-)• Move : ROM limited

Assessment: 1. Suspect.Close fracture at the right clavicle2. Suspect.Close fracture at the left thigh3. Open fracture at the left lower leg grade II

Management • Stop oral intake• Immobilization • IVFD RL 20 drips/min • Cefazoline injection 1g• Ketorolac 30mg injection 1 amp• Inj. Tetagam• Laboratory examination• Radiology examination

Routine Laboratory examination

• Haemoglobin : 14,1 gr/dl• White Blood Count : 24.400 gr/dl• Platelets : 345.000/ul• Random blood glucose : 152 mg/dl• Hematocrit : 41 %• CT/BT : 7’/3’

Radiology examinationThorax AP• There was fracture of the middle third of the right clavicle

Left femur Ap/Lat: • Fracture of the lower third of the left femur

Left cruris AP/Lat• Fracture of the middle third of the left tibia •

Diagnose 1. Close fracture of the middle third of the right

clavicle2. Close fracture of the lower third of the left femur3. Open fracture of the middle third of the left tibia

grade II

Consult to orthopedic surgery division:• Performed debridement and ORIF emergency

Operative Report ( right clavicle)• Patient in supine position with general anasthesia• Aseptic and antiseptic procedure• Performed incision at the clavicle• Identified fracture site• Performed reposition and fixation with small dep plate 6 hole 6 screw• Rinse the wound with normal saline until clean• Closure the wound with primary suture At the left femur• Aseptic and antiseptic procedure• Performed lateral incision • Identified fracture site• Performed reposition and fixation with Broad plate 9 hole 8 screw• Bleeding control• Rinse the wound with normal saline until clean• Closure the wound with primary suture and one tube drain

At the left cruris• Aseptic and antiseptic procedure• Performed antero lateral incision.• Performed debridement of the wound by peroxida + povidone iodine +

Nacl 0.9%• Identified fracture site• Perfomed 1 leg screw at thye fracture site of the tibia• Performed reposition and fixation with narrow plate 8 hole 8 screw• Bleeding control• Rinse the wound with normal saline until clean• Closure the wound with primary suture.•

Post operative diagnose1. Close fracture of the middle third of the right

clavicle2. Close fracture of the lower third of the left

femur3. Open fracture of the middle third of the left

tibia grade II

Follow upDate S O A P

8/10/14POD III

- General Condition : goodBlood pressure : 120/70 mmHgPulse : 86x/minuteRR : 22x/minuteS/L at the right clavicleL : wound operation goodF : NVD (-)M: ROM limitedS/L at the left thigh regionL : wound operation goodF : NVD (-)M: ROM limitedDrain : S/L at the left lower extremityL : wound operation goodF : NVD (-)M: ROM limited

1. Close fracture of the middle third of the right clavicle

2. Close fracture of the lower third of the left femur

3. Open fracture of the middle third of the left tibia grade II

Post ORIF at the right clavicle

Post ORIF at the left femur

Post ORIF at the left tibia

IVFD RL 20 drips/iCefazoline Inj 1g/12hourKetorolac 30mg Inj / 8hoursRanitidin 50mg Inj / 12hoursElevation extremity

4 okt 2014

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