Duty Report

Thursday, 4th July 2019

ON DUTY

Consultant : dr. Ismail Dilawar, SpBTKV

Team on duty : dr. Bayu/ dr. Maida / dr. Deni / dr. Mirwan – dr. Elgah
dr. Iqbal/ dr. Amal/ dr. Roi/ dr. Chano
dr. Popon/dr. Inan/dr. Fira
dr. Rama/ dr. Pras/ dr. Tamtam
dr. Ai/ dr. Uno/ dr. Guntur/dr. Dedy
dr. Dani/ dr. Ray/ dr. Ali/ dr. Yodi/ drg. Arfah/ drg. Wayan

Patients
Operation 2
Inpatient 1
Outpatient 1
Total 4

Signature Consultant

1st Operation
Baby Boy Mrs. Uswatun Khasanah, 3 day, 439-16-16
Preoperative diagnosis:
Imperforated anus without fistula high level anomaly, suspected viscus perforation

Post operative diagnosis:

Imperforated anus without fistula high level anomaly, rectum perforation, meconium plug

Supporting data:
Chief Complain
Absent of anus detected on birth

History:
 The patient was a neonate, boy with the history of delivery by caesarian section
due to history of previous caesarian sectio
 The baby had a gestational age of 37 weeks, birth weight of 2.505 grams
 The mother routinely controlled to midwives during pregnancy
 After birth, no anus was identified. The patient did not have a fistula on his
perineum. Urine was clear, no evidence of meconium in urine.
 No vomitus, the abdomen become enlarge and eritematous

Physical examination
Adequate contact
General condition: moderately ill
Vital signs: HR 143 x/minute, RR: 45 x/minute, Temp: 36.8oC, SpO2: 99%
Birth weight: 2.505 grams

Head : Normocephal
Eyes : Not anemic, not jaundice
Thorax : vesicular on both sides, rales (-), wheezing (-)
Heart. : 1st and 2nd heart sound normal, no murmur nor gallop
Abdomen. :
I : distended, erithematous
A : bowel sound diminished
Pal : muscular guarding (+), abdominal tenderness difficult to be assessed
Per: hypertymphanic, liver dullness (+)
Extremities: warm, no edema, CRT<2”

Perineal : anal dimple (+), fistula (-)

Genital : testicular was found in scrotum

Laboratory Findings (2/4/2019)

CBC: 18,2/49,7/24180/240000
Ur/Cr: 38/1
AST/ALT: 42/9
E: 135/4,9/110
PT/APTT: 1x/1.2x

Treatment:
 Already done laparotomy, primary hecting of rectum perforation, rectum biopsy,
transverse colostomy
 Informed consent
 Decompression, nothing per oral
 Insertion of orogastric tube
 Insertion of Foley catheter  urine was clear, target UO 1-2cc/Kg/hour
  Rehydration + IVFD maintenance
 Antibiotic
 Preoperative consultation to the pediatrician and anesthesiologist on duty

Intra-operative finding :
Procedure: Laparotomy, primary hecting of rectum perforation, rectum biopsy,
transverse colostomy
1. Patient on supine position under general anesthesia.
2. A and antisepsis on operation field
3. Transverse incision in left lower abdomen from skin, subcutaneous tissue, fascia,
and muscle
4. Peritoneum was opened, there was gasses, serous ascites, and meconium came
out then suctioned
5. Incision was widden transversally to medial, perforation was identified in rectum,
around 3 cm length, rectum was dilated, Descenden colon was small, with
meconium in hard consistency was palpaple intraluminally, transverum colon
until ileum was dilated
6. Meconium was suctioned from perforation site in rectum, decided to made
transverse colostomy
7. Colotomy on the transverse colon was performed to decompress ileum and the
colon
8. A tube then inserted to distal colostomy, spooling was done using normal saline,
passing the descended colon, exit to perforation part of the rectum. The tube also
passed and connected to the rectum
9. Refreshing of perforation site in rectum, biopsy of the rectum was sent to
pathology anatomy department, then the perforation was closed with primary
suture with simple interrupted suture
10. Then a transverse incision in left upper abdomen was made from skin,
subcutaneous tissue, fascia, and muscle
11. Loop of colon was exteriorated, and fixated to the fascia and peritoneum
12. Abdominal cavity was cleansed using normal saline, then was dried.
13. The wound was closed in layers.
14. Colostomy was dressed accordingly
15. The operation commenced.

Follow Up
 2nd Operation
Mrs. Sugiyanti, 37 yo, 430-30-46

Diagnosis Pre-Surgery:
Left Pleural effusion
Left breast carcinoma NST Gr. 3 TxNxM1 with lung metastasis, post MRM and six cycles of
chemotherapy

Diagnosis Post Surgery:

Left Pleural effusion
Left breast carcinoma NST Gr. 3 TxNxM1 with lung metastasis, post MRM and six cycles of
chemotherapy

Supporting data :

History taking
Chief Complaint:
● Shortness of breath that worsens since 1 week before admission

History of present illness:

● Patient start to felt shortness of breath since 1 month before admission, and worsen since 1
week before admission.
● There was no fever, chest pain, hemoptoe, nausea, nor vomitus
● The patient was diagnosed having left breast cancer since November 2017, and already done
modified radical mastectomy on March 2018 at Suyoto hospital, and 6 cycles of
chemotherapy in RSCM on June 2018
● There was no history of needle thoracosynthesis before

Physical Examination
Primary Survey
Airway: clear
Breathing: spontaneous, RR 28x/min, saturation 95%, on O2 nasal canule 5 lpm
Lung:
Inspection: left hemithorax movement was left at expiration
Palpation: vocal fremitus of left hemithorax was decreased
Percussion: dull at left hemithorax
Auscultation: decreased vesicular sound at left hemithorax, no rhales nor crackles
Prepared to be inserted canule thoracostomy with connection to water seal drainage system
Circulation: BP 128/76mmHg, HR 90x/min
Disability: Alert

Eyes : pale conjungtiva (-), icteric sclera (-)

Heart: Heart sound I/II was normal, no murmurs or gallop
Abdomen : No distention, no mass was palpable, normal bowel sound, no tenderness, tympanic
Extremities : warm, CRT<2 seconds, edema
Local status: there was a mastectomy scar at left hemithorax, no recurrent lesion at the site, no
palpable lymph node at left and right axilla

Supporting Diagnostic
Laboratory (4/7/2019)
CBC : 13.6 /415/9010/484000
Albumin : 3.54
AST/ALT : 21/10
Ur/Cr : 31.1 / 0.71
Electrolyte: 140/4,1/ 99
PT /APTT : 1x/0.9x

Chest X-Ray Pre WSD (22/4/2019)

Bilateral pleural effussion, especially at the left hemithorax side, with multiple nodule at lung suspected
metastases

Have been done :

● Insertion of left canule thoracostomy connected with water seal drainage system
● Oxygenation
● Informed consent
● Antibiotic
● Analgetic
● Inhalation
● Mucolytic
● Chest physiotherapy

Operation Report

1. Patient in half-sitting position with abduction of the left arm

2. A and antiseptic operating area
3. Infiltration with lidocaine 2% in the left 5th intercostal midaxillary line
4. Incision through the cutaneous, subcutaneous
5. Thoracostomy canule was inserted, initial production of 410 ml of serous hemorrhagic fluid,
no bubble.
6. Canule was connected to WSD system, there was an undulation, no bubble
7. Canule was fixated to the skin
8. The wound is covered by gauze
9. Operation commenced

Post canule insertion, the patient was stable, alert, RR 20x/min, O2 saturation 99%, on O2
Nasal canule 5 lpm, BP 120/80, HR 88x/min

Chest X-Ray Post WSD (22/4/2019)

Bilateral pleural effussion, especially at the left hemithorax side, compared to the previous photo is
reduced, with multiple nodule at lung suspected metastases

FOLLOW UP

The patient is hospitalized in 421E, with stable hemodynamic, RR 20x/min, saturation 99%,
canule production is 1300cc/8 hours, seroushemorhagic, undulation (+), bubble (-)