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Duty report

Sunday, March 26th 2017

Surgical resident : Dennis W Pratama, M. D.
Surgical interns : Danny, Deza, Melda

Attending surgeons in-charge
• Pediatric surgery : Catur Soetisna, M. D., Ph D., SpBA
• Digestive surgery : Ponco Prasodjo .M.D, SpB KBD
• Orthopedic surgery : A. B. Mulyanto, MD, SpOT
• Plastic & Reconstructive surgery : Guntoro, M. D., SpBP (RE)
• Neurologic surgery : Luqman Ma’ruf, M. D., SpBS
• Oncologic surgery : Maria T. Goeltom, M. D., SpB
• TCV surgery : Wijoyo Hadi Moersito, M. D., SpBTKV
• Urologic surgery : Nugroho Budi Utomo, M. D., SpU

Patients’ recapitulation
Total
Outpatients 0
Inpatients 1
Operations 2
Died 0

2. Right sided pleural effusion.Operations 1. Mr U. small cell carcinoma of the right lung  Planned for an immediate right pleural space tap utilizing the insertion of a cystofix drain. Intracerebral Hemorrhage of the right temporal  Immediate craniotomy . Mrs R. 55 yo. 58 yo.

1. the neck.Inpatient • Boy A. to be admitted at the burn unit • .5 yo. the anterior trunk and the left upper extremity  fluid resuscitation . Burn secondary to scalding gr IIA – IIB 18 % TBSA of the head.

. 847401 Chief Complaint Shortness of breath that become worse since a week before admission .Mrs. U 58 y.o.

and now he’s taking chemotherapy of the 4 th cycle with ifosfamid and doxorubicin on Haematologic and Oncologic Division • The patient is a heavy smoker since in Junior High school. but now he quitted smoking since 10 years ago . • The patient had a history of small cell carcinoma of the right lung.History of Present Illness • The patient complained of a shortness of breath since 3 weeks ago that become worse since a week before admission.

allergy (-). bronchial asthma (-) .History of Past Illness • HPN(-).

icteric sclera -/.. CRT < 2” . .4oC • Eye: anemic conjunctivae -/-. • Extremity: warm. • Lungs: vesicular breath sounds +/+. • Heart: S1 & S2 normal.. wheezing -/. moderately ill • ABP 130/70 mmHg. RR 26x /minute. t: 37. edema (-).Physical findings • CM. rales -/-. HR 110x /minute. • Abdomen: supple no tenderness nor muscular rigidity. murmur (-). gallopping rhythm (-) . normal bowel sounds.

Radiological findings chest AP xray .

000/μL • Kalium : 3.5 mg/dL .Laboratory findings • Hgb : 10.4 g/dL% • Hct : 29 % • WBC : 10200/μL • Natrium : 128 mmol/L • Trombocyte : 256.7 mmol/L • Ureum : 83 mg/dL • Chloride : 92 mmol/L • RBS : 206mmol/l • Creatinine : 0.

Pre-operative working diagnosis. • Right sided pleural effusion • small cell carcinoma of the right lung .

Management (Wijoyo Hadi Moersito.. M. • Informed consent • IVFD • Antibiotic • Analgetic . SpBTKV) • Planned for an immediate right pleural space tap utilizing the insertion of a cystofix drain. D.

Melda Surgical report Bleeding : approximately 300 m. Some serohemorrhagic liquid came out on needle aspiration • . D. region • The cystofix was then fixed to the skin and eventually connected to WSD system • The operation was commenced • Infiltration anesthesia using 2% lidocaine at the 5th interspace (right thorax). 1st assistants: Danny. M. • Patients was sitting with his right forearm on maximal abduction • A and antisepsis and drapping of the right thorax • An approximate 300 ml serohemorrhagic effusion came out . Operator: Dennis W Pratama.l.

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Post operative diagnosis • Right-sided pleural effusion • small cell carcinoma of the right lung .

cystofix production  Antibiotics  adequate Analgetics Mucolytics Inhalation Chest physiotherapy .Post operative care  Monitor the vital signs. post operative-pain.

she was immediately intubated by the time she arrived in ER. In the hospital patient vomit 3 times. The patient immediately brought to hospital to get the treatment.o. CT scan of head showing an intracranial hemmorhage of . 55 y.Mrs. History of Present Ilness Since a day ago. the patient suddenly loss of consciousness while walking in her house. R. 850140 Chief Complain Sudden loss of consciousness.

History of past illness • Hemorrhagic CVD (2011)  Conservative treatment .

Physical Examination Primary survey: A: clear  intubated B: spontaneous. rhales -/-. wheezing -/-. C: BP: 170/ 90 mmHg. 99% O2 saturation on 6 L/minute O2 supplementation. Vesicular sounds + / +. warm extremities D: E2M3V on ETT . Heart Rate 74 x / minute. 24x / min.

P: 76 tpm. gallop (-) • Pulmo : vesicular sounds +/+.Physical Examination • CM. RR : 24 tpm.4C • Eyes : no anaemic. rhales -/-. anisochoric pupil 5mm/3mm • Cor : 1st & 2nd heart sound normal. warm • Motoric 4444 / 3333 4444 / 3333 . T:37. wheezing -/- • Abdomen : within normal limits • Extremity : CRT<2”. murmur (-). BP: 170/90 mmHg.

000/μL • Kalium : 3.7 g/dL% • Hct : 30 % • WBC : 13200/μL • Natrium : 128 mmol/L • Trombocyte : 256.2 mmol/L • Ureum : 83 mg/dL • Chloride : 92 mmol/L • RBS : 185mmol/l • Creatinine : 0.Laboratory findings • Hgb : 10.7 mg/dL .

Chest X Ray .

Head CT Scan .

SpBS): • Immediate craniotomy • Head elevation 30’ • Antibiotic • Analgesic • To be admitted in ICU following surgery .D.Working Diagnosis • Intracerebral Hemorrhage of the right temporal • Plan (Lukman. M.

D. • Patient was in supine position with general anesthesia • A and antisepsis was performed in the surgical • Corticotomy was performed at the temporal lobe.l. and than burrhole was performed in 6 spots • Craniectomy was performed • Cerebral edema was noted . Surgical report Bleeding : approximately 100 m.. Operator: Lukman. M. D. hematoma was suctioned field and surroundings • • Haemostasis was performed cranium bone was kept in the patient’s abdomen under the • Question mark incision was • subcutaneous tissue Operation wound was stitched layer by layer • performed from skin down to Operation was commenced cranium. SpBS 1st assistants: Moh Ismet Febriadi M.

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Post Operative Orders  Monitor the vital signs and the post operative pain  Antibiotic  Analgetic 2x 1 vial of intravenous Neurobion 4x 150 cc of intravenous mannitol 2 x 250 mg of intravenous citicholin .

Today Condition .

Boy. the hot water was accidentally poured over the patient’s body. There was no gas explosion. the chest. The patient was referred from the private hospital in Pondok Kopi due to lack of facilities. A. the left shoulder and the left hand. Chief Complain Burn injury History of Present Ilness When her mother was boiling water for making milk. 1. He got burn injury on the face. No hoarseness after the incident.5 y.o. .

99% O2 saturation. Primary survey: A: clear. B: spontaneous. clear yellowish. D: alert. rales -/-. / kg / h. Urine production is currently 0. warm extremities. wheezing -/-. No increasing work of breathing. 30x / min.l.Physical findings. Vesicular breath sounds + / +. no hoarseness. No circular eschar on the chest.5m. C: Heart-rate 124 x / minute. .

grade IIA-B – 2%. . Face. grade IIA-B – 12%.l. grade IIA-B – 2% Chest./ kg / hour.E: Burns grade 2A-B 18%.l. Left shoulder grade IIA-B – 2%.-2m. Neck. F: Fluid requirement: Resuscitation (2ccx16 kg x 18% TBSA) + (16kg+75 cc) = 1776 cc First 8 hours = 893 cc Following 16 hours = 893 cc Free drinking (Formula Milk) Fluid titration as the urine target was 1m.

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P: 76 tpm. gallop (-) . • Pulmo : vesicular sounds +/+. RR : 20 tpm. • CM.Physical findings. • Local state : Face. rhales -/-. BP: 130/80 mmHg. grade IIA-B – 2% Chest. grade IIA-B – 12%. Neck. Left shoulder grade IIA-B – 2%. murmur (-).8 oC • Eyes : not anaemic. t:36. • Extremity : CRT<2”. wheezing -/-. • Abdomen : within normal limits. • Cor : normal 1st & 2nd heart sounds. . warm. grade IIA-B – 2%.

Laboratory findings • Complete Blood Count: Hgb 12.2 mmol/L /97 mmol/L .3 g/dL/ Hct 37(%) / WBC 14500/ μL / Platelet Count 373.000/ μL • Electrolytes: Na/K/Cl 134 mmol/L/4.

Working diagnosis • Burn secondary to scalding gr IIA – IIB 18 % TBSA of the head. the anterior trunk and the left upper extremity . the neck.

SpBP-RE(K)} • To be admitted at the Burn Unit.Plan of management {Guntoro. • Antibiotic. • Intravenous fluid rescucitation • Free drinking • Wound treatment using MEBO ointment. M. • Analgesic. D.. .

Today’s condition .

It was a pleasure for me to serve These 3 clients during my watch .