DUTY CASE REPORT

Thursday 03 Oct 2022

Consultant

Dr Bambang Suprapto Sp.B(K)BD

Team in charge
Dr Boyke S. Sp.U
VIK Dr Yudhy Arius Sp.BP
COR Dr Dadik A.S Sp.B (K) BA
JAY Dr Hendri Purnama Sp.OT
Dr Zainal Abidin Sp.B(K)Onk
Dr Ivan Joalssen Sp.BTKV
A.W.S General Hospital Dr Grace Sianturi Sp.BS
SAMARINDA
Name : K A Gender : Female
Age : 1 years old Weight : 8.5 kg
Presenting : Pain in the lower extremity
Complaint

History of : Patient presented to the ER with pain in the lower

presenting
complaint extremity after sustaining burn from hot water, 30
minutes prior to admission. The parent of the child
was carrying hot water when it accidentally fell and
poured on the child. The parent immediately took the
child the ER.

Past : • Pulmonary Hypertension

Medical
History • Thalassemia (routine evaluation at the outpatient
with Dr Elsa paediatric hematology specialist).
Was previously on routine medication Sildenafil 1
mg / 6 hours (medication ceased 1 month ago)
• Complete Vaccination history
Name : KA Age : 1 year old Gender : Female

Primary Survey
• Airway : clear, no stridor / gargling
• Breathing : clear, chest wall movement symmetrical and
adequate, RR 20, SpO2 = 98% Room Air
• Circulation : clear, warm extremity, CRT < 2 seconds, Heart Rate
153 x/min,
• Disability : GCS 15, Pupil symmetrical 2 mm, reactive
• Exposure : Burn wound in the right lowe extremity
Secondary Survey
• Head and Neck : within normal limits
• Thorax : within normal limits
• Abdomen : within normal limits
• Extremity :
• right femoral region, in anterior lateral and posterior lateral
region, with erythema, bullae, RS 4%
Name: KA Age : 1 year old Gender : female Blood Test
Leucocyte : 20.92 x 103 / μL
Hemoglobin : 12.7 12.0-16.0 g/dL
Platelet : 466 x 103 / μL
Glucose : 88 <200 mg/dl
Ureum : 44.8 17.0-43.0 mg/dL
Creatinine : 0.3 0.6-1.1 mg/dl
Natrium : 138 135-155 mmol/L
Kalium : 4.5 3.6-5.5 mmol/L
Chloride : 109 98-108 mmol/L
HbA2 : 2.4 % 1.9-3.0 % (12-24
months)
HbF : 5.7 % 0.5-3 % (12-24
months)
Bleeding Time (BT) : 3
Clotting Time (CT) : 9
SarsCoV2 : negative
HbSAg : Non-Reactive
AbHIV : Non-Reactive
 Name : KA Age : 1 year old Gender : Female

ECHO (3 June 2022)

• Situs solitus
• AV & VA concordance
• Drainase V. Pulm : normal
• Ruang jantung ; Balance
• Katup :
• Mitral : normal
• Aorta : normal
• Triuspid : normal
• Pulmonal : Normal
• Septum Atrium dan Ventrikel intake
• Arcus Aorta di kiri normal, tidak ada CoA
• Ejection Fraction : 87%
• Fraction Shortening : 54%
• Kesimpulan : Normal Echocardiograph
Name : KA Age : 1 year old Gender : Female
Name : KA Age : 1 year old Gender : Female
Name : KA Age : 1 years old Gender : Female

Assessm : - Burn Injury grade IIA/B RS 4% Right Lower Extremity

ent due to scald injruy
Thalassemia
Pulmonary Hypertension

Plan : - IVFD D51/4NS 850 cc / 24 hours

- Inj ampicillin sulbactam 4 x 200 mg
- Inj Gentamicin 3 x 7 mg iv
- Admit under Plastic Surgery
- Joint Care with Paediatric Specialist
Name : M N Gender : Male
Age : 5 years old Weight : 23 kg
Presenting : Pain in the facial region
Complaint

History of : Patient presented to the ER with open wound in the lip

presenting
complaint and chin region. Patient fell down whilst climbing up
stairs at the market place, and hit his face on the
stone at the pavement. No loss of consciousnes, No
vomitting. After the event, Patient rushed back home
running, with his friend.

Past : • Complete Vaccination history

Medical
History • No other past medical history
Name : M N Age : 5 year old Gender : male

Primary Survey
• Airway : clear, no stridor / gargling
• Breathing : clear, chest wall movement symmetrical and
adequate, RR 20, SpO2 = 98% Room Air
• Circulation : clear, warm extremity, CRT < 2 seconds, Heart Rate
110 x/min
• Disability : GCS 15, Pupil symmetrical 2 mm, reactive
• Exposure : wound in the facial region
Secondary Survey
• Thorax, Abdomen, Extremity : within normal limits
• Head and Neck :
• Lacerated wound lower lip 3 cm, with muscular tissue at the
base of the wound
• Lacerated wound sub-mentalis 4 cm, with bone tissue at the
base of the wound
• Pain on palpation of the right temporo-mandibular joint region
Name : M N Age : 5 year old Gender : male
Name : M N Age : 5 year old Gender : male
hematosinus
hematosinus
Name: M N Age : 5 year old Gender : male Blood Test
Leucocyte : 15.73 x 103 / μL
Hemoglobin : 12.3 12.0-16.0 g/dL
Platelet : 368 x 103 / μL
Glucose : 110 <200 mg/dl
Ureum : 17.0-43.0 mg/dL
Creatinine : 0.6-1.1 mg/dl
Natrium : 139 135-155 mmol/L
Kalium : 3.4 3.6-5.5 mmol/L
Chloride : 108 98-108 mmol/L
Bleeding Time (BT) : 3
Clotting Time (CT) : 9
SarsCoV2 : Negative
HbSAg : Non-Reactive
AbHIV : Non-Reactive
Name : MN Age : 5 years old Gender :male

Assessm : - Lacerated wound in the lower lip region

ent - lacerated wound in the submentalis region

Plan : - IVFD D51/2NS 1,560 cc / 24 hours

- Inj cefotaxime 3 x 500 mg iv
- Inj metamizole 3 x 250 mg iv
- Tetagam intramuscular injection
- Admit under Plastic Surgery
- Plan for Debridement and wound repair
Name : K R Gender : male
Age : 17 years old
Presenting : Pain in the left lower extremity
Complaint

History of : Patient presented to the ER with pain in the left thigh

presenting
complaint after sustaining a penetrating stab wound from a knife
whilst trying to break up a fight, which happened
around 23:00 pm on 30/9/2022 (One day prior to
admission). The Patient was brought to HIS Sendawar
hospital 1 after the event. At the HIS hospital, his vital
signs remained stable, the wound was sutured (5x
external suture), and referred to AWS hospital after
being given Antibiotics (Ceftriaxone), and Tetagam
injections.
Name : KR Age : 17 year old Gender : male

Primary Survey
• Airway : clear, no stridor / gargling
• Breathing : clear, chest wall movement symmetrical and adequate, RR 20,
SpO2 = 98% Room Air
• Circulation : clear, warm extremity, CRT < 2 seconds, Heart Rate 78 x/min,
Blood Pressure 120/80 mmHg
• Disability : GCS 15, Pupil symmetrical 3 mm, reactive to light
• Exposure : sutured wound at the left lateral femoral region
Secondary Survey
• Head and Neck : within normal limits
• Thorax : within normal limits
• Abdomen : within normal limits
• Extremity :
• 6 cm wound at the left lateral femoral region,
• pulsating mass (+),
• thrill (+),
• edema (+).
Name : KR Age : 17 year old Gender : male

Pulses
• Femoral artery ++/++
• Popliteal artery ++/++
• Dorsalis Pedis artery ++/++
• Tibialis anterior artery ++/++
• Tibialis Posterior artery ++/++
• warm extremity
• palpable thrill in the lateral and medial femoral region

SpO2 left lower extremity

• dgt 1 : 98%
• dgt 2 : 98%
• dgt 3 : 99%
• dgt 4 : 98%
• dgt 5 : 97%
Name: KR Age : 17 year old Gender : male Blood Test
Leucocyte : 16.3 x 103 / μL
Hemoglobin : 15.6 12.0-16.0 g/dL
Platelet : 260 x 103 / μL
Glucose : 133 <200 mg/dl
Ureum : 17.0-43.0 mg/dL
Creatinine : 0.6-1.1 mg/dl
Natrium : 135-155 mmol/L
Kalium : 3.6-5.5 mmol/L
Chloride : 98-108 mmol/L
Bleeding Time (BT) :
Clotting Time (CT) :
Rapid antigen : Negative
HbSAg : Non-Reactive
AbHIV :
Name : KR Age : 17 years old Gender : male

Assessm : - susp Traumatic AV fisula

ent - susp pseudoaneurysma left femoral artery

Plan : - IVFD RL 1,500 cc / 24 hours

- Inj ceftriaxone 2 x 1 gram iv
- Inj ketorolac 3 x 30 mg iv
- Inj Omeprazole 1 x 40 mg iv
- CT Angiography bilateral lower extremity from common
iliac artery until tibialis anterior-posterior artery
- Admit under Thoracic,Cardio-Vascular Surgery
- plan for vascular exploration
Thank you