Duty Report

Thursday, May 2nd 2019

TEAM
Consultant : dr. Parintosa Atmodiwirjo, SpBP-RE

Team
dr. Tiffany/dr. Lim/dr. Filipus/dr. Jackson-dr. Fatah
dr. Erwin/dr. Ansyah-dr. Guntur/dr. Uno/dr. Fitri
dr. Nilam/dr. Kasih/dr. Uthe
dr. Maruto/dr. Naffi/dr. Jodi
dr. Fikri/dr. Uno/dr. Alka/dr. Don/
drg. Martha/drg. Sissy

Patients
Operation 2
Inpatient 0
Outpatient 2
Total 4

Sign Consultant

Operation # 1
 Mrs. Nuraini/ 38 years old / 430-57-85

Preoperative diagnosis :
 Bilateral pneumothorax post tracheostomy
 Non-Hodgkin malignant lymphoma on the neck with history of chemotherapy

Postoperative diagnosis:
 Bilateral pneumothorax post tracheostomy
 Non-Hodgkin malignant lymphoma on the neck with history of chemotherapy

Supporting data :

 Patient was consulted with bilateral pneumothorax after tracheostomy by the ENT department
due to impending airway tract obstruction
 Patient had shortness of breath since 2 days before admission
 Patient had history of non-hodgkin malignant lymphoma and had undergone chemotherapy R-
CHOP 5 cycles and R-ICE 4 cycles

Physical examination
General Status
Fully alert, moderately ill
Blood Pressure 135/75 mmHg, Heart Rate 104x/min, respiratory rate 24x/min, temperature 37.0oC

Head: Normocephalic
Eyes: anemic conjunctiva (-), icteric sclera (-)
Neck: multiple solid mass with the largest size 5x3x2cm
Thorax:
Heart: Normal heart sound, murmur (-), gallop (-)
Lungs:
Inspection: both hemithoraces were symmetrical
Palpation: crepitation +, fremitus was decreased on both hemithoraces
Percussion: hypersonor on both hemithoraces
Auscultation: decreased lung sound on both hemithoraces, rales -/-, wheezing (-)
Abdomen:
Inspection : flat
Auscultation : bowel sound (+)
Palpation : supple, muscular guarding (-)
Percussion : tympanic
Extremity: capillary refill time < 2 sec, warm

Laboratory Findings 2/5/2019

CBC : 11.8/32.3/8710/219.000
Blood Gas Analysis : 7.44/34.1/113.6/23.6/98
Electrolyte : 134/3.7/108
Blood glucose : 107.4
Ur/Cr : 10/0.84
OT/PT : 26/20
PT/APTT : 0.9/0.9

Chest X-ray post tracheostomy (2/5/2019)

 Bilateral pneumothorax
 Suspicious of pneumomediastinum
 Subcutaneous emphysema on bilateral supra-infraclavicular, bilateral axilla, and bilateral lateral
hemithoraces
 Aortic calcification
 Trachea canule with stoma as high as C7-T1 vertebrae and tip 2.8cm from carina

Management

 Bilateral chest tube insertion and connected to WSD system

 Informed Consent
 Antibiotic
 Analgesic
 Intravenous fluid drip (IVFD)
 mucolytic
 Chest physiotherapy

Surgery Report

1. Patient on erect position, left arm extended above the head

2. A dan antisepsis of the operative field and surrounding area, patient was drapped
accordingly
3. Local anesthesia with infiltration of 2% lidocaine over the 5th ICS, anterior axillary line
4. Incision on the left 5th costae, anterior axillary line, through the skin and subcutaneous
tissue.
5. The muscle was disected bluntly until air came out of the pleural cavity.
6. 24Fr chest tube was inserted and connected to WSD system. Undulation (+), bubble (-),
FEB (-)
7. Chest tube was fixated to skin with silk 2.0
8. The wound was closed with tulle and gauze
9. Patient was still on erect position, right arm extended above the head
10. A dan antisepsis of the operative field and surrounding area, patient was drapped
accordingly
11. Local anesthesia with infiltration of 2% lidocaine over the 5th ICS, anterior axillary line
12. Incision on the right 5th costae, anterior axillary line, through the skin and subcutaneous
tissue.
13. The muscle was dissected bluntly until air came out of the pleural cavity.
14. 24Fr chest tube was inserted and connected to WSD system. Undulation (+), bubble (-),
FEB (-)
15. Chest tube was fixated to skin with silk 2.0
16. The wound was closed with tulle and gauze
17. Operation concluded

Follow Up
 Operation # 2
Mr. Dalih Sukarnadi/ 57 years old / 438-91-88

Preoperative diagnosis :
 Strangulated mechanical bowel obstruction due to suspected tumor of sigmoid colon

Postoperative diagnosis:
 Tumor of sigmoid colon suspected malignant T4bN0M0

Supporting data :

 Unable to defecate since 4 days before hospital admission

 Patient was still able to pass gas yesterday
 The complaint was accompanied by abdominal pain, worsened since 1 day before admission
 Nausea (+), vomiting (+)
 Patient felt the abdomen getting bloated
 Since the past 7 months, patient had changes in bowel habit. The stool was hard and small
resembling goat’s stool
 History of blood in stool was denied.
 Body weight decreased 3 kg during the last 4 months
 No history of hypertension and diabetes.

Physical examination
General Status
Fully alert
Blood Pressure 140/90 mmHg, Heart Rate 106x/min, respiratory rate 21x/min, temperature 37.2oC

Head: Normocephalic
Eyes: anemic conjunctiva (-), icteric sclera (-),
Thorax:
Heart: Normal heart sound, murmur (-), gallop (-)
Lungs: Vesicular, no rales, no wheezing
Abdomen:
Inspection : distended
Auscultation : metallic sound
Palpation : no tenderness, muscular guarding (-), mass (-)
Percussion : hypertympanic
Extremity: capillary refill time < 2 sec, warm

Digital rectal examination: normal sphincter tone, ampulla recti was collapsed, no mass was found.
blood (-), stool (-)

Laboratory Findings 30/4/2019

CBC 14,0/43,2/14.620/962.000
MCV/MCH/MCHC 67,7/21,9/32,4
SGOT/SGPT 31/26
Ur/Cr 29,7/0,65
Electrolyte 136/4,2/108
PT/APTT 1x/1x
Random blood glucose 112

Abdominal X-ray (1/5/2019)

 In accordance with obstructive ileus on large intestine
 No pneumoperitoneum
 Dilatation of small and large bowels until descending colon
 Multiple air-fluid level
 No free air

Management
 Exploratory laparotomy – Hartmann like procedure
 Informed consent
 Nothing per oral (NPO)
 Insertion of nasogastric tube (NGT) for decompression
 Rehydration
 Foley catheter insertion target urine output of 0.5-1.0 mL/kgBW/hour
 Antibiotic
 Analgesic
 Perioperative consultation

Surgery Report

1. Patient on supine position under general anesthesia

2. Asepsis and antisepsis of operative field and surrounding area.
3. Midline incision 3 fingers above umbilicus until 2 fingers above pubic symphysis,
penetrating through the skin, subcutaneous tissue, white line, and peritoneum.
4. When peritoneum was opened, there was serous fluid 100ml.
5. The liver was palpated, smooth surface, nodule (-)
6. The small bowels – sigmoid colon was dilated
7. There was a mass on the sigmoid colon attached to the parietal peritoneum and left ureter
8. Sigmoid colon was difficult to released due to distention, unable to be retracted
9. Transversal colostomy was performed
10. Bleeding was controlled
11. Abdominal cavity was rinsed with warm sterile saline and dried using sterile gauze
12. Operation wound was sutured layer by layer.
13. Operation concluded
Follow Up