Morning Report

Saturday, October 4th, 2014

Team on duty

RSUDZA

dr. Maria Meildi

dr. Joko Siswanto
dr. Haji Ifradin Pinim
dr. Raja Raharja MP
dr. M. Andri Mulia
dr. Nasrul Haidi
dr. Andri feisal Nst
dr. Bobbi HE Fermi

(Chief)
(Coordinator)
(Case report)
(Medical Report)
( Medical Report)
( Medical Report)
(Documentation)
(Documentation)

No
1
2
3
4
5

Distribution of surgery patient

Emergency room patient
Hospitalize
Out of clinic
/961912
Refuse medical advice
Passed away

6 Hospitalize room

Room

Total
Patients
Patients
Patients
Patient

Jeumpa 1
Jeumpa 2

27/28 bed
26/28 bed

Jeumpa 3

25/28 bed

Jeumpa 4

26/28 bed

PJT

23/26 bed

ICU

6 Patients

HCU

3 Patients

ICCU

0 Patients

PICU

2 Patients

NICU

6 Patients

ICU ADULT

HCU

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
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

NICU

PICU

06/07/14

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
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
Age
Sex
Address

Phone
MR
Patient came
Driving Liscence

: Ervan
: 36 years old
: Male
: Paloh lada, Kec.Dewantara,
Kab.Aceh utara
: 085277125470
: 1021431
: 02.15 PM
: (-)

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 examination
Head CT-Scan
:
SCALP hematoma at the right fronto temporal region
There was no fracture
There was hiperdens area at the left temporal regionMinimally 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 region
3. EDH at the left temporal
4. Edema cerebri
Consult to Neurosurgery Division :
Hospitalize
Conservative theraphy evaluation of gcs
Evaluation Head CT Scan 3 days later

Follow up
Date
8-10-2014
Ad IV

S
Pain (-)

O
VS/: general
condition :
good
GCS : E4 M6
V(afasia)
BP :
120/90mmH
g
Pulse : 88
beats/mnt
RR : 20
breaths/mnt

1.

2.

3.

4.

A
Mild head
injury
EDH
at
the
left
temporal
region
ICH at the
bifrontal
region
Edema
Cerebri

P
IVFD NaCl
0,9% 10
drips/mnt
Ceftriaxone
Inj 1 gr/12 hr
Ketolorac Inj
30mg /8 hr

Patient identity
Name
Age
Sex
Address
MR
Phone
Driving license
Patient came at

: Heri
: 26 years old
: Male
: Saree, Kec.Saree,.Kab.Aceh Besar
: 1021429
: 085373220460
: (-)
: 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
Disability

: Blood Pressure: 110/80 mmHg, Pulse: 80 beats/min

: 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
secret (-)

: (-)

: stool (+), blood (-),

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

03.00

110/80mmHg, 90 beats/minutes

50cc

04.00

130/80mmHg, 70 beats/minutes

60cc

05.00

110/90mmHg, 80 beats/minutes

50cc

06.00

130/80mmHg, 90 beats/minutes

80cc

07.00

120/70mmHg, 80 beats /minutes

70cc

08.00

110/90mmHg, 90 beats/minutes

50cc

09.00

120/80mmHg, 70 beats/minutes

60cc

10.00

130/70mmHg, 90 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

Diagnosed
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. 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 Diagnosed

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

Follow up
Date
8-10-14
POD III

S
Pain (-)

O
Consciousness :
Compos Mentis
BP:100/70
Pulse : 100 x/menit
RR: 26 x/menit
Temperatur : 36,8 0C
Urine
Abdominal region :
L/S at the abdominal
region :

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

A
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

P
IVFD RL 20
drips/min
Inj. Cefazoline 1 gr
Inj. Ketorolac 30 mg

Patient Identity
Name
Age
Sex
Address

:
:
:
:

MR
:
Phone
:
License
:
Patient came

Juan mahfuzar
29 years old
Male
Lam lagang Kec.Bandar raya Kota
Banda Aceh
1021427
08126900428
(+)
: 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

Circulation

: Spontaneous, 20 breaths/min
: Blood pressure : 130/70 mmHg, Heart rate 82
beats/min
: GCS E4M6V5 = 15,isochoric pupil (3mm/3mm).

Disability

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 clavicle
2. Suspect.Close fracture at the left thigh
3. 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
White Blood Count
Platelets
Random blood glucose
Hematocrit
CT/BT

: 14,1 gr/dl
: 24.400 gr/dl
: 345.000/ul
: 152 mg/dl
: 41 %
: 7/3

Radiology examination
Thorax 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
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

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 diagnose

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

Follow up
Date
8/10/14
POD III

S
-

O
General Condition :
good
Blood pressure :
120/70 mmHg
Pulse : 86x/minute
RR
: 22x/minute
S/L at the right
clavicle
L : wound operation
good
F : NVD (-)
M: ROM limited
S/L at the left thigh
region
L : wound operation
good
F : NVD (-)
M: ROM limited
Drain :
S/L at the left lower
extremity
L : wound operation
good
F : NVD (-)
M: ROM limited

A
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

P
IVFD RL 20 drips/i
Cefazoline Inj
1g/12hour
Ketorolac 30mg Inj /
8hours
Ranitidin 50mg Inj /
12hours
Elevation extremity