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Morning Report

Saturday, July 15th 2017


Team on duty
dr. Munawar (Chief)
dr. Muharriansyah (Chief)
dr. M. Andri Mulia (Jaga 1)
dr. Arfan Asmadi (Jaga 2)
dr. Muhhamad Reza (Jaga 2)
dr. Mhd Al Fazri (Jaga 3)
dr. Ike Yoganita Bangun (Jaga 3)
dr. Novli Ardiansyah (Jaga 4)
dr. San Winata Badiri (Jaga 4)
dr. Muhammad Iqbal (Jaga 5)
RSUDZA dr. Ricky Aldofan (Jaga 6)
NoS Distribution of surgery patient Room Total

1 Emergency room patient 25 Patients

2 Hospitalize 15 Patients
3 Out of clinic 8 Patients
4 Refuse medical advice 0 Patients
5 Passed away ICU D
ICU C Marullah/ 80 yo/ Post Radical Nefrectomy Sinistra due to
Kidney Tumour Sinistra + Post Laparotomy eksploration
due to infiltration kidney tumour to colon desenden +
ligamentum Treitz + adhesi grade III/ POD 1

6 Hospitalize room Jeumpa 1 28 /28 bed


Jeumpa 2 28 /28 bed
Jeumpa 3 28 /28 bed

Jeumpa 4 28 /28 bed


PJT 27 / 28 bed
ICU 3 Patients
ICU C 1 Patients
ICCU 0 Patients
ICU • M. Ikbal/ 17 yo/ Post Craniectomy due to ICH a.r. Ganglial Basal + Post
laparostomy due to abdomen distention due to sepsis/ POD 13
ADULT • Muinah/ 46 yo/ Post Craniotomy Tumour Evacuation a.r Frontal Dextra/ POD
2
• Ainiah/ 52 yo/ Post craniotomy + evakuasi ICH + SDH ec mild Head injury +
ICH SDH a/r Temporopariaetal/ POD 1

ICU • Darlin Yunus/ 65 yo/ Post CABG 4 Graft on Pump due to APS CCS II due to
CARDIAC CAD 3 VD LM disease + EF 75%/ POD 2

PICU • Fathul Khairi/ 6 mo/ Post Remove VP Shunt + Debridement due to Infected
VP Shunt + Ventrikel Empyema/ POD 5
• Alvi Nazira/ 4 yo/ Post VP Shunt due to Hydrocephalus/ POD 2
• Saputra/ 12 yo/ Osteosarcoma ar femur dextra Post op disarticulation Hip
joint/ POD 0

NICU • By. Nur Iradah Yusuf/ 10 days/ Post VP Shunt due to Hydrocephalus +
Meningocele/ POD 7
• Adelia Sahra/ 5 days/ Meningoenchepalocele/ AD 3
3
Patient identity
• Name : Jodi Mustajab
• Age : 15 years old
• Sex : Boy
• Address : Jambo Papeun, Meukek,
Aceh Selatan
• Phone : 081360037123
• MR : 113 45 76
• Drive License : (-)
• Admission Time : 18.45 PM
Time Response
Date/ Examinati Laboratory Radiology Time of Date/
Time on hour Examination Examination Diagnostics Time DPJP
patient Send Result Send Result patient out
came from ER
to ER
15 July 18.50 PM 19.00 21.00 20.00 20.45 20.45 PM 01.00 Dr. Imam
2017 PM PM PM PM SpBS

18.45
PM
Chief Complaint
Decrease of consciousness

Patient illnes History


• The patient was referred from Calang district hospital
with chief complaint decrease of consciousness for 6
hours ago.
• Initially the patient got ride on a motorcycle then
struck by another motorcycle from opposite
direction and fell off
• There was history of nausea and vomiting. History of
seizure (-).
• No eye response, withdraws from pain and no verbal
response (intubation)
Physical examination
Primary survey
A : Clear with ETT
Collar neck
B : Spontaneous, 24 beats/minute
Right Left Planning
haemithorax haemithorax
Inspection Symmetrical, there was no X-ray
tracheal deviation, JVP in normall
limit, Excoriated wound (-)
Palpation Subcutaneous Subcutaneous
emphysema (-) emphysema (-),
Percussion Sonor sonor
Auscultation Vesiculer (+), Vesiculer (+), rh
rh (-), Wh (-) (-), Wh (-)
C : BP : 110/80 mmHg, HR : 92
beats/minute
D : GCS E1M4Vx, unisochoric pupil, light
reflex (4mm/ 3mm)
E:
L.S right frontal
I : Swelling (+), Excoriated wound (+), monocle
(+)
P: Discontinuity of bone (-)
L.S right antebrachii
I : Swelling (+), Excoriated wound (+), cubitus
varus (+)
P: Discontinuity of bone (+), NVD (-)
M : ROM limited

L.S right thigh


I : Swelling (+), Excoriated wound (+),
Discrepency (+) shortening
P: Discontinuity of bone (+), NVD (-)
M : ROM limited
Right Left

True lenght 87 cm 92 cm

Apperance lenght 90 cm 95 cm

Anatomical lenght 44 cm 49 cm
Secondary Survey
Head 
L.S right frontal
I : Swelling (+), Excoriated wound (+), monocle
(+)
P: Discontinuity of bone (-)
Neck  in normal limit
Thorax  in normal limit
Abdomen  in normal limit
Upper extremity 
L/S right antebrachii Ap/L
I : Swelling (+), Excoriated wound (+), cubitus
varus (+)
P: Discontinuity of bone (+), NVD (-)
M : ROM limited
Lower extremity 
L/S right thigh AP/L
I : Swelling (+), Excoriated wound (+),
Discrepency (+) shortening
P: Discontinuity of bone (+), NVD (-)
M : ROM limited
Assessment
1. Severe Head Injury
2. Suspect close fracture of the right antebrachii
3. Suspect close fracture of the right thigh
Management
• Stop Oral Intake
• Head up 30 0
• Oxygen 5 L/ min via ETT
• NGT  greenish
• IVFD NaCl 0,9% 1500 cc/24 hours
• Inj. Ceftriaxone 1g
• Inj. Ketorolac 30 mg
• Inj. Omeprazole 40 mg
• Folley cathether  80 cc, yellowish
• Laboratory examination
• Radiology examination
Laboratory result
• Hb : 12,8 gr/dl
• WBC : 12.900/ul
• Platelet : 244.000 /ul
• Ht : 40%
• CT : 8 minute
• BT : 2 minute
Radiology examination
Head CT-Scan :
• There was SCALP hematoma at the right temporo-parietal
region
• There was hyperdense area at the right parietal region 
SAH
• Sulci and gyrus was narrow
• Ventricle and cysterna was narrow
• There was no midline shift
Cervical Lateral
Loss of lordotic

Thorax AP
In normal limit

Right antebrachii AP/L


There is discontinuity of the upper third of the right
radius ulna
Right femur AP/L
There is discontinuity of the middle third of the right
femur
Diagnose:
1. Severe head injury
2. Diffuse axional injury grade III
3. Close fracture of upper third of the right radius ulna
4. Close fracture of the middle third of the right femur
Consult to Neurosurgery Division :
Craniectomy decompression

Consult to orthopaedic division :


Skin traction and ORIF femur elective
Backslab and ORIF radius ulna elective
Operation report
• Performed reverse question mark incision at
the right temporo-parietal region
• Performed 8 burrholes
• Bone was saw by gigly and opened
• Perfomed dura hit stiches
• Duramater was tense
• Performed durafascia graft
• Bone was put on subgaleal
• Left 1 tube drain
Post Op Diagnosed
1. Severe head injury
2. Diffuse axional injury grade III (Post craniectomy
decompression)
3. Close fracture of upper third of the right radius ulna
4. Close fracture of the middle third of the right femur
Follow up
Date S O A P

17th july On BP : 130/70 mmHg 1. Severe head injury • Head up 300


2017 ventilato HR : 82 beats/mnt (ICD 10 CM S09.0) • O2 5L/ minute via
r RR : 18 breaths/mnt on 2. Diffuse axional ETT
POD 2 ventilator injury grade III • IVFD NaCl 0,9 %
Temp : 36, 7 C (Post craniectomy 1500 cc/ 24 hours
decompression) • Inj. Ceftriaxone 1
NGT : 40 cc yellowish (ICD 10 CM S06.2) gr/12 hour
GCS : E1 M2 Von 3. Close fracture of • Drip pct 1 gr/ 8
ventilator upper third of the hours
Isochoric pupil right radius ulna • Drip propofol 0,8
Ø3mm/3mm (ICD 10 CM S52.5) Mcq/ hour
4. Close fracture of • Drip fentanyl 0,3
L/S at the right temporo- the middle third of Mcq /hour
parietal region the right femur
L : wound closed by (ICD 10 CM S72.9) • Wound care
gauze, dry (+), Drain : + 60
cc/24 hours,
serohemorage

Urin : 30 cc/hours
Patient identity
• Name : Irwan syahputra
• Age : 20 years Old
• Sex : Male
• Address : Karang Baru, Aceh tamiang
• CM : 11 327 29
• HP : 0852 969000651
• License : (-)
• Admission time: 21.30
Time Response
Date/ho Examina Laboratory Radiology Hour of Date/h DPJP
ur tion Examination Examination Diagnos our
patient hour tics patient
came to Send Result Send Result out
ER from ER

15th feb 21.35 21.45 23.00 22.15 23.00 23.00 04.30 Dr.
2017 Imam
SpBS
21.30
Chief complain
• Decrease of consciousness
Presenting history
• Patient was referred from Aceh tamiang district
hospital to Zainoel Abidin emergency room with
chief complaint decrease of consciousness for 3
days.
• Previously the patient was riding motorcycle
with helmet but suddenly struck by another
motorcycle from opposite then he fell off.
• History of lucid interval (-), seizure (-)
• History of nausea and vomiting (+).
• Eyes open to verbal command, motoric response
obey commands and verbal response
incomprehensible
Physical examination :

Primary survey

A : Clear , Collar neck

B : Spontaneous, RR = 20 breaths/minute
Right Left Planing
hemithorax hemithorax

Inspection Symmetrical, trachea in midline, JVP X-Ray


in normal limit
Palpation Subcutaneous Subcutaneous
emphysema (-) emphysema (-)
Percussion sonor Sonor

Auscultation Ves (+), rh(-), wh Ves (+), rh(-) wh


(-) (-)
C : BP: 110/80 mmHg, Pulse : 90 beats/minute

D : GCS 13 = 13 E3M6V4, isochoric pupil 3 mm/ 3 mm,


light reflex (+/+)
E:
S/L at the right parietal region
L : Swelling (+), excoriated wound (+)
F : Discontinuity of bone (-)
Secondary survey
S/L at the right parietal region
L : Swelling (+), excoriated wound (+)
F : Discontinuity of bone (-)
Thorax  in normal limit

Right Left Planing


hemithorax hemithorax

Inspection Symmetrical, trachea in midline, JVP X-Ray


in normal limit
Palpation Stem fremitus Stem fremitus
normal normal
Percussion sonor Sonor

Auscultation Ves (+/+), rh(-/-), Ves (+/+), rh(-/-),


wh (-/-) wh (-/-)
Abdomen  in normal limit
Upper extremityin normal limit
Lower extremityin normal limit
Assesment
Moderate head injury
Management :
• Stop oral intake
• Head Up 30°
• 02 8L/minute
• IVFD NaCL 1500 cc/24 hours
• Inj. Metamizole sodium 1gr
• Folley catheter  initial 80 cc, yellowish
• Laboratory examination
• Radiology examination
Laboratory result
• HB : 12.5 g/dl
• HT : 35 %
• White blood count : 16.900 u/l
• Platelet : 406.000 u/l
• CT/BT : 7’/2’’
• Blood glucose ad random : 174 mg/dL
Radiology result
Head CT-Scan
• Scalp haematome at the right temporo-parietal
region
• There was no discontinuity of bone
• Hyperdense appearance at the right temporo-
parietal region  ICH
• Sulcus and gyrus were narrowed
• Ventricel system was narrowed
• Midline shifts to the left >0,5 cm
• Cervical lat
Lordotic

• Thorax Ap
In normal limit
Diagnose
1. Moderate head injury
2. ICH at the right temporo-parietal region
Consult to Neurosurgery Division

• Craniectomy evacuation ICH emergency


Operative report
• Performed horse shoe incision on the right temporo
parietal region
• Deepened layer by layer
• Bone was saw by gigly and skull was opened
• Perfomed dura hit stiches
• Duramater was tense
• Found ICH about 80 cc  evacuation ICH
• Bone was put on subgaleal
• Wound was closed by primary hecting and left 1 tube
drain
Post Operative Diagnose
1. ICH at the right right temporo-parietal region
(Post craniectomy evacuation ICH) (ICD 10 CM
S52.1)
2. Moderate head injury(ICD 10 CM S09.90)
Follow up
Date S O A P
17th july General Condition 1. Post craniectomy • Head Up 30⁰
2017 : moderate evacuation ICH due to • O2 8L/minute via
POD 1 BP : 110/80 mmHg ICH at the right right facemask
HR : 94 x/minute temporo-parietal • Diet 4x 150 cc
RR : 20 x/minute region (ICD 10 CM • IVFD NaCL 20
T : 36,7oC S52.1) drips/minutes
GCS :11, E2 M5 2. Moderate head • Ceftriaxone Inj.
V3, isochoric pupil injury(ICD 10 CM 1gr/12 hrs
(3mm/3mm) S09.90) • Inj. Metamizole
sodium 1 gr/12 hours
L/S at right parietal • Inj. Ranitidine 50 mg/
region : 12 hours
L : gauze was dry,
drain 40 cc • Wound care
Time

04.30 The Patient arrived at OR

05.00 The patient was anesthetized

05.30 Began to incise

06.30 The surgeon required a carrison device but was not


available and there was no any circular nurse
06.45 There was still no any circular nurse coming, the
surgeon decided to stop the operation
07.30 The circular nurse came

08.30 Operation continued


Patient identity
• Name : Saifuddin M. Isa
• Age : 43 years old
• Sex : Male
• Address : Gp. Meurandeh, Kec. Bandar Baru,
Kab. Pidie Jaya
• CM : 1 13 06 55
• Phone : 082365851552
• Admission time : 04.30 WIB
Time Response
Date/hour Examinatio Laboratory Radiology Hour of Date/hou DPJP
patient n hour Examination Examination Diagnostics r patient
came to ER out from
Send Result Send Result ER
16th july 04.40 04.50 07.30 05.30 06.15 06.15 10.00 Dr . M.
2017 yusuf
SpB-KBD
04.30
Chief Complaint
• Pain at the whole abdominal region

History of present illness


• Patient was referred from Pidie Jaya district hospital
to Zainal Abidin emergency room with a chief
complaint pain at the whole abdominal region post
trauma for 12 hours.
• Previously the patient was driving a minibus, but the
brake was broken and struck a wall
• The history of nausea and vomiting (-).
• History decrease of consciousness (-).
• The patient also complaint pain at the left chest.
• Eyes response spontaneously, verbal response
orientated, motor response obey command
Physical examination
Primary Survey
• A : Clear
• B : Spontaneous, RR: 24 breaths/ minute
Right haemithorax Left haemithorax Planning
Inspection Symmetrical, there was no tracheal X-Ray
deviation, JVP in normal limit, Excoriated
wound (+)
Palpation Emphysema Emphysema
subcatenous (-) subcatenous (+)
Percussion Sonor Dullness at lower
side
Auscultation Vesiculer (+), rh (-), Vesiculer (-), rh (-),
wh (-) wh (-)
• C : Heart rate 94 beats/minute,
Blood Presure: 110/80 mmHg
• D : GCS 15 (E4 M6 V5), isochoric pupil 3mm/3mm
• E : L/S at the abdominal region :
I : Symmetrical, distension (+), excoriated wound (+)
A : Bowel sound (+)
P : Pain at the whole abdomen (+), muscular rigidity(+)
P : Liver dullness (-), Tympani (+)
Digital rectal examination
Spinchter ani : loose
Ampula : Faeses, collaps (-)
Mucosa : Smooth
Glove : Faeces (+), blood (-)
Secondary Survey:
• Head and Neck  in normal limit
• Thorax 

Right haemithorax Left haemithorax


Inspection Symmetrical, there was no tracheal deviation, JVP in
normal limit, Excoriated wound (+)

Palpation Emphysema Emphysema subcatenous


subcatenous (-) (+)
Percussion Sonor Dullness at lower side
Auscultation Vesiculer (+), rh (-), wh Vesiculer (-), rh (-), wh (-)
(-)
• Abdomen 
L/S at the abdominal region :
I : Symmetrical, distension (+), excoriated wound
(+)
A : Bowel sound (+)
P : Pain at the whole abdomen (+), muscular
rigidity (+)
P : Liver dullness (-), Tympani (+)
• Upper extremity  in normal limit
• Lower extremity  in normal limit
VAS : Moderate

Mild 1-3 Moderate 4-6 Severe 7-10


Non opioid + Opioid + nonopioid Opioid + nonopioid
adjuvant + adjuvant + adjuvant
- COX-2 - Codein - Oxycodone
- Ibuprofen - Propoxyphene - Morphine
- Aspirin - Hydrocodone - Hydromorphone
- Acetaminophen - Tramadol - Fentanyl
Time BP HR T RR Urin
05.00 120/80 94 36,7 22 60 cc
06.00 120/70 94 37,1 22 50 cc
07.00 120/80 90 37,2 20 60 cc
08.00 120/70 88 37,7 24 70 cc
09.00 110/80 92 36,8 24 60 cc
10.00 120/80 96 36,7 20 70 cc
11.00 110/70 92 36,7 24 60 cc
Assessment
• Diffuse peritonitis due to suspect hollow organ
perforation due to blunt abdominal injury with
stable hemodynamic
• Blunt thoracal injury with stable hemodynamic
Management
• Stop oral intake
• O2 8L/minute via facemask
• IVFD RL 1800 cc/24 hours
• Ceftriaxone inj 1 gr
• Tramadol 100 mg Inj.
• NGT  Decompression
• Urinary catheter  clear (Initial urine 60 cc)
• Laboratory examination
• Radiology examamination
Laboratory results:
• Hb : 15.9 gr/dL
• White blood count : 5.100/ul
• Platelet : 359.000/ul
• Hematocrit : 53%
• CT : 7’
• BT : 3’
• Blood glucose ad random : 151 mg/dl
• Ureum : 26 mg/dl
• Creatinin : 1,2 mg/dl
• potassium : 4,5mmol/L
• Natrium : 139 mmol/L
• Cloride : 104 mmol/L
Radiology result
Thorax AP
• There was discontinuity of the 2nd, 3rd, 4th, 5th lateral
ribs of the left haemithorax
• Free air at the right subdiafragma
• Left Costophrenicus angle was blunt 
hematothorax
• Radiopaque appearance at the left haemithorax 
lung contusion
Diagnose :
1. Diffuse peritonitis due to suspect hollow organ
perforation due to blunt abdominal injury with
stable hemodynamic
2. Haematothorax at the left hemithorax due to blunt
thoracal injury with stable hemodynamic
3. Fracture of the 2nd, 3rd, 4th, 5th lateral ribs of the left
haemithorax
4. Emphysema subcutaneous at the left hemithorax
5. Lung contusion at the left hemithorax
Consult to digestive surgery division :
•Laparotomy exploration

Consult to TCV division :


•Chest tube at the left hemithorax
•Platting costae elective
Operative report
WSD
• Performed incision at the ICS V midaxillary line of the
left thorax
• Deeper layer by layer
• Inserted thorax tube FR 28  bubble (-), undulation
(+), blood (+) 100 cc
Operative report
Laparotomy
• Performed midline incision
• Peritoneum was opened  came out enteric content +
200 cc
• Rinse with normal saline
• Exploration intestine found perforation at ileum + 0,5
cm, 170 cm from lig. treizt
• Performed refreshning of the edge wound
• Performed primary suture
• Left 2 tube drain
Post op diagnose :
1. Diffuse peritonitis due to ileum perforation due to
blunt abdominal injury with stable hemodynamic
(AAST grade 2) (Post laparotomy exploration +
primary repair ileum)
2. Haematothorax at the left hemithorax due to blunt
thoracal injury with stable hemodynamic (Post
insertion chest tube)
3. Fracture of the 2nd, 3rd, 4th, 5th lateral ribs of the left
haemithorax
4. Emphysema subcutaneous at the left hemithorax
5. Lung contusion at the left hemithorax
Date S O A P
17th july Pain (+) General condition : moderate 1. Diffuse peritonitis due to ileum • IVFD RL 1800 cc/ 24
2017 BP : 120/80 mmHg perforation due to blunt hours
HR : 88 beats/mnt abdominal injury with stable • Ceftriaxone inj 1 gr/ 12
POD1 RR : 20 breaths/mnt on hemodynamic (AAST grade 2) hours
T : 36.5’C (Post laparotomy exploration + • Tramadol 100 mg/ 8
NGT : 60 cc primary repair ileum) ( ICD 10 hours
CM K65.9) • Drip PCt 1 gr/ 8 hours
L/S abdominal 2. Haematothorax at the left • Inj. Omz 40 mg/ 12
I : Symmetrical, distension (-) hemithorax due to blunt hours
Drain 1 : 80 cc serous- thoracal injury with stable • Nebule 1 flc / 8 hours
hemorage hemodynamic (Post insertion
Drain 2 : 70 cc serous- chest tube) (ICD 10 CM C94.2) • Non per oral diet
hemorage 3. Fracture of the 2nd, 3rd, 4th, 5th
A: Bowel sound (-) lateral ribs of the left
P: Soepel (+) Pain (+) haemithorax (ICD 10 CM • Observation vital sign
P: Liver dullness (+), Tympani S22.3) and urine
(+) 4. Emphysema subcutaneo us at • Observation acute
Urin : + 40 cc/h the left hemithorax (ICD 10 CM respiratory failure and
T81.82) WSD
Right Left haemithorax Planning
haemithorax 5. Lung contusion at the left • Platting costae elective
Inspection WSD (+), undulation (+), buble (-), X-Ray
hemithorax (ICD 10 CM S20.21)
production (-), there was no tracheal
deviation, JVP in normall limit,
Excoriated wound (-)

Palpation Emphysema Emphysema


subcatenous subcatenous (+)

Percussion Sonor sonor


Auscultation Vesiculer (+), rh Vesiculer (+), rh (-
(-), wh (-) ), wh (-)