Night Shift Report

Monday, March 7th 2022

Consultant on duty : Dr. dr. Yussy Afriani Dewi, Sp. T.H.T.K.L(K)

Chief on duty : dr. Goesti

Doctors on duty : dr. Revy
dr. Rizal
 1. Girls, 6 years old (01.00)
Chief Complain : Swallowed a coins
Patient complained of swallowed coins since 1 day prior admission. When put the coins in
the mouth and accidentally swallowed. Currently the patient complains of feeling stuck in
the throat, painful in swallowing, and difficulty in swallowing.
Drooling (-), shortness of breath (-), cough (-), Fever (-), Hoarseness (-).
Complaints of colds (-), fever (-), anosmia (-). History of contact with covid patients (-).
Allergies to food (-), drugs (-).
Because of his complaint the patient was taken to the Dustira Hospital and a chest X-ray
was performed with the result that there were foreign bodies (coins), then the patient was
referred to the RSHS for further treatment.
 PHYSICAL EXAMINATION
Generally State : compos mentis,
HR : 90 x/m, RR : 20 x/m, T : 36,50C
SpO2 : 99 % free air room air
Stridor Inspiration (-) Stridor Expiration (-)
Suprasternal Retraction (-), Epigastrium (-), Intercostal (-)

ORL-HNS examination :
Right and Left ear : external auditory canal not hyperemic +/+ , discharge -/-, cerumen -/-,
ear drum intact +/+, light reflex +/+, retro auricular not hyperemic +/+
Nasal cavity : mucosa not hyperemic +/+, discharge -/-, inferior turbinate eutrophic +/+,
septum deviation (-), air passage +/+
Oropharynx : Tonsil T1 – T1 not hyperemic, Pharynx Not Hyperemic
MF : symmetrical, no cranial nerve paralysis
Neck: no lymph node enlargement
 Laboratory Finding
Hemoglobin: 14.1 Blood Sugar level : 90
Hematocrit: 43.5 SGOT: 18
Erythrocyte: 5.47 SGPT: 18
Leukocyte: 12.270 Natrium 137
Thrombocyte: 475.000 Kalium 3,8
PT 11,70 Cloride 100
APTT 23.80 Calcium ion 5.17
INR: 1.05 Magnesium : 2.1
Ureum: 15.0
Creatinine: 0,36 PCR TCM Sars Cov-2: Negative
Thorax X-Ray
Neck Soft Tissue
WD/ : Foreign body (coin) at Suspicious Esophagus Region

Management:
•Observation of vital sign
•IVFD KaenMg3 1500cc/24hours
•Plan Consult to Pediatric Pediatric Pinere Team for covid 19
screening
•Plan Consult Anesthesiology Department
•Plan to perform exploration and extraction foreign body (LED coin)
via rigid esophagoscopy under General Anesthesia
•Patient is fasting
•Therapy
•Methylprednisolone 3x12,5mg (IV)
Pediatric Department Answers
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Anesthesiology Department Answers
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THANK YOU