Monday, 5th February 2018

In Emergency Installation we receive … patient, consist of

NO Diagnose Plan
1 Laceration wound dimana Wound toilet and suturing
 1 patient Amoxicillin 500mg/8 hours
Mefenamic acid 500mg/8 hrs
orally
 Discharged
2 Hydrochepalus komunikans Keep warm
 2 patient Oxygenation
Maintain OGT
Pro MSCT of head
ER
3 Intracranial haemorrhage GCS Oxygenation
E4M6V5=15 (vol. 37 cc) of right Head up 30
temporoparietal Observation
CKD stg. V Ketorolac 30mg/8 hrs
Hipertension stg II intravenous
Joint management with
No Diagnosis Rencana
4 Uncomplicated closed fracture of 1/3 Splint application
proximal of right humerus Paracetamol syr 250mg/8 hrs orally
transverse displaced c.b fall Elective ORIF
 1 patient ER

5 Uncomplicated closed fracture 1/3 Splint application

middle of right femur Ketorolac 30mg/8 hrs intravenous
comminutif c.b trafic accident
Elective ORIF
 1 patient
ER
6 Fracture of right acetabulum Splint application
Uncomplicated closed fracture of Ketorolac 30mg/8 hrs intravenous
right plateau tibia (Schatzker Elective ORIF
type I)
ER
Uncomplicated closed fracture of 1/3
distal of right ulna oblique
undisplaced c.b trafic accident
 1 patient
No Diagnosis Rencana

7 Compression fracture of 1st Ketorolac 30mg/8 hrs intravenous

vertebra lumbal region Pro laminectomy
frankle E c.b traffic Pro instrumentation
accident
Pro Fusion
 1 patient
 GERD

8 Spondilitis VL 4 th susp. TB Ketorolac 30mg/8 hrs intravenous

Lung TB X-ray thorax
 1 patient Join management with Internal
Medicine Management
 ER
9 Soft tissue tumor of left hip sin Oxygenation
susp malignancy BNO 2 position
GxT2bN0M0
USG abdomen
 1 patient
X-ray Pelvic AP/Lat
Insisi biopsy
 ER
10 CKD st V on HD Oxygenation
 2 patient Pro double lumen
Join management with Internal
Medicine Management
 MRK 1, ER
11 Incisional incarcerated hernia Oxygenation
Post laparotomy cb perforated Maintain NGT
appendectomy 2015 Maintain urethral catheter
Post laparotomy cb generalized Ceftriaxone 2g/24 hrs intravenous
peritonitis cb expulsi IUD
Laparatomy hernioraphy
2001
 R2A
 1 patient
Monday, 5th February 2018
Case Report (11.55)
A Female, 63 years old came to Kariadi Hospital, reffered from K.R.M.T
Wongsonegoro Hospital with diagnose ileus obstruction. Already
inserted IV line, NGT and urethral catheter. Brought plain abdominal X-
Ray, abdominal USG.

Chief complain : can’t defecate

History of present illness :

1 week before admission to the hospital patient felt there is a lump
beneath her umbilical. The lump is standstill, and appears briefly, pain (-
), nausea (-), vomitting (-), fever (-), urination (+) yellowish, defecation
(+).
1 day before admission patient can’t defecate, nausea (+), vomiting (+),
pain (-). By her family she was brought to K.R.M.T Wongsonegoro
Hospital and perform plain abdominal X-Ray, abdominal USG. By the
doctors in charge, patient was diagnosed there is an infection in her
bowel, then she was referred RSDK.

History of past illness:

2001  generalized peritonitis cb expultion of IUD (RSDK)
1995  Perforated appendicitis (RSDK)
Physical examination :
General Condition : moderately ill
Consciousness : GCS E4M6V5=15
Vital sign :
RR : 20 times per minutes, regular, enought in depth
PR : 90 times per minutes, regular tone
BP : 130/70mmhg
T : 36,5 ºC (A)
Pain Scale : 3-4 VAS

Head/neck
Conj.palp was not anemic
Sclera wasn’t icteric
Dry lips (-)
forehead skin turgor decrease (-)
Inserted NGT  green + 400 cc
Thorax:
Lungs
I : static : left hemithorax = right hemithorax
dynamic : left hemithorax = right hemithorax
Pa : stem fremitus right hemithorax = left hemithorax
Pe : sonor on both hemithorax
Au : vesicular sound +/+, no additional sound
Heart
I : IC not visible
Pa : IC palpated on the 5th ICS, 2 cm medial from left MCL
Pe : heart configuration within normal limit
Au: regular heart sound, murmur (-) gallop (-)
Abdomen:
I : There is an appearance of lump on the right side of umbilically,
scar (+), lump look reddish, lump surface is equal to the
rounded skin, darm contour (-), venectation (-)
Pa : Soepel, defance (-), DM (-), lump is palpable on the right side
of umbilically, diameter of the mass is aproximately 10 cm,
chewy (+), mobile (-), pain on the pressure was (+).
Pe : Tymphani , liver dullnes (+), side dullness (+), shifting
dullness (-).
A : Bowel sound (+) increased

Extremity Sup Inf

Cold acral -/- -/-
Motoric 555/555 555/555
Sensoric +/+ +/+

Genitalia externa : female, with in normal limit,

inserted urethral catheter 16Fr
Radiology (Ketileng Hospital) 30/01/2018 :
BNO 2 position
Working diagnose (12.15) :
Incisional incarcerated hernia

Initial Management (12.20) :

IpDx :
S:-
O:-
IpTx :
Inf RL 20 drops / minute
Maintain NGT  flow
Mantain DC no 16 Fr  inital production 250 cc yelowish clear
Inj. Cefazoline 1g intravenous 30 minute before incision
Pro hernioraphy laparatomy
IpMx :
Complaint, general condition, vital sign, Routine blood, electrolite,
and coagulation study, ECG, GDS, Ureum, Creatinin.
IpEx :
Informed consent : diagnose, prognose, operation procedure
Laboratory study (14.30) :
Hb : 12,8 gr% (12 – 15 gr%)
Ht : 41.5 % (35 – 47 %)
L : 22.900/mmk (5 – 15/mmk)
Tr : 434.000/mmk (150.000 – 400.000/mmk)
GDS : 117 mg/dl (80 – 140 mg/dl)
Ureum : 39 mg/dl (15 – 39 mg/dl)
Creatinin : 0.8 mg/dl (0,6 – 1,3 mg/dl)
Na : 129 mmol/L (136 – 145 mmol/L)
K : 4.0 mmol/L (3,5 – 5,1 mmol/L)
Cl : 84 mmol/L (98 – 107 mmol/L)
PPT/K : 10.4”/11,1” (9,4” – 11,3”)
APTT/K : 26.7”/32,2” (23,4” – 36,8”)
Operation report (16.05 - 17.30)
- Patient lied down on supine position under GA
- Aseptic and antiseptic on operation area
- Made the incision on former operated wound, depeended layer by layer
started from the healty side
- Identification : Hernia sac below umbilical diametre 2 cm
Pinched of Ileum and omentum
- Release of pinched ileum and omentum  colour is pink, check in
passase is good  look vital
- Refresh the edge of the fascia
- Sutured fascia with PDS loop no 1
- Sutured the operating wound layer by layer
- Operation finished
Post op diagnosed (17.35):
Incisional incarcerated hernia
 Post hernioraphy laparotomy
Management Post Op (17.40) :
- Dx :
S:-
O:-
- Tx :
Inf RL 20 drops per minutes intravenous
Maintain DC  Evaluate the production
Ketorolac 30 mg/12 hrs intravenous
- Mx :
Complaint, general condition, vital sign, operation wound
- Ex :
Informed consent : Operation finding, Prognose
Follow up H + 1
Monday, 5th February 2018