EMERGENCY SURGICAL SERVICES

Wednesday, April 12th 2023

Consultant On Site :
DR. Dr Nur Rahmat Lubis, SpOT, Subsp. TLBM

The Attending Doctors :

Chief : dr. M. Febriandi Djunaidi
Pra Chief : dr. Didy Kurniawan
Captain : dr. Fadhli Aufar K
P1/P2 : dr. Jaya Ndaru P
Ward : dr. Satya Agusmansyah
Junior : dr. Ilham Taufan I
dr. Jefry Angola
dr. Grady Christian
Observer : dr. Eldhi Aprian
dr. Ferdian Riztavy
dr. M. R. Emerald
Trauma patient : 1 patients
Non trauma patient : 2 patients
Total : 3 patients
 TRAUMA CASES (1)

1. Yuda Putra Bakti / ♂ / 13 years old

Dx. Moderate head injury GCS 11 + Left parietooccipital lobe EDH +
Cerebral oedema + Linear fracture of the left occipital bone
 NON TRAUMA CASES (2)

1. Suhardi bin Nasron / ♂/ 67 years old

Dx. Abdominal aortic aneurysm + Stage II hypertension

2. Dahlan bin Basnan/ ♂ / 39 years old

Dx. Obstructive jaundice ec susp CBD distal obstruction + Moderate
acute cholangitis
TRAUMA CASES
1. Yuda Putra Bakti / ♂ / 13 years old
Admitted on Wednesday, April 13th 2023 at 00.49 AM
DIAGNOSIS
Moderate head injury GCS 11 + Left parietooccipital lobe EDH +
Cerebral oedema + Linear fracture of the left occipital bone

MANAGEMENT
 Head up 30º
 O2 NRM 10 Lpm
 IVFD NaCl 0.9% gtt XX/m
 Inj. Ceftriaxone 1 gr/12 hours IV
 Inj. Paracetamol 1 gr/8 hours IV
 Conservative

Patient was treated in the ward

NON TRAUMA CASES
1. Suhardi bin Nasron / ♂/ 67 Years old
Admitted on Wednesday, April 12th 2023 at 14.56 PM

DIAGNOSIS
Abdominal aortic aneurysm + Stage II hypertension

Management
 IVFD Ringer Lactate gtt XX/ m
 Inj. Ceftriaxone 1gr/12 hours IV
 Inj. Paracetamol 1gr/ 8 hours IV
 CTA of Thoraco-abdominal with contrast

Management of Cardiologist Department

 Candesartan 8mg/24 hours PO
 Bisoprolol 2.5mg/24 hours PO
 Echocardiografi

Patient was treated in the ward

2. Dahlan bin Basnan/ ♂ / 39 years old
Admitted on Wednesday, April 12th 2023 at 19.33 PM

DIAGNOSIS
Obstructive jaundice ec susp CBD distal obstruction + Moderate acute
cholangitis

Management
 IVFD Ringer Lactate gtt XX/ m
 Inj. Ceftriaxone 1gr/12 hours IV
 Inj. Metronidazole 500 mg/8 hours IV
 Inj. Metamizole 500mg/ 8 hours IV
 Inj. Omeprazol 40mg/ 24 hours IV
 Inj. Vit K 10mg/ 12 hours IV
 Pro. MRCP

Patient was treated in ward

EMERGENCY REPORT
1. By. Ny. Fitri Nopitasari / ♂ / 9 days
Admitted on Saturday, 8th 2023 at 23:28 PM

DIAGNOSIS PREOPERATIF
Susp atresia jejunoileal

INTRA OPERATIF
 We performed transverse incision at supraumbilical
 Deepen the incision layer by layer into the peritoneal cavity
 Identification obtained multiple atresia at 5 cm from lig. Treitz's.
Multiple atresia along 15-25 cm from lig. Treitz's.
 Atresia at 40 cm from the lig. Treitz's and 60 cm from lig. Treitz's
 We performed ileoileal side to side anastomosis on atresia at 40 cm
and 60 cm from lig. Treitz’s
 We performed end to side jejunoileal anastomosis
 We performed a Bishop-Koop stoma
 Bleeding treated
 The surgical wound was sutured layer by layer
DIAGNOSIS POST OPERATIF
Multiple atresia jejunoileal post exploratory laparotomy+ Bishop-Koop
procedure + side to side ileoileal anastomosis

Patient was treated in NICU

2. Eka Saputra/ ♂ / 34 years old
Admitted on Thursday, March 30th 2023 at 21.36 PM

DIAGNOSIS PRE OPERATIF

Clinical Dx: Decrease of consciousness GCS 13 + Wound
dehiscence + Hemiparesis 
Etiology Dx : SOL intracranial post craniectomy tumor removal
Topic Dx : Temporoparietal sinistra
Additional Dx : Post External Ventricular Drainage

INTRA OPERATIF
 We performed incision on the old wound, deepened to cranium
 We found pus ± 10cc
 We performed debridement
 We found artificial durameter was not viable
 We continued incision on the left femur, deepened until fascia lata
visible. The fascia was freed from surrounding tissue
 We performed duraplasty with fascia donor
 Bleeding treated
 The surgical wound was sutured layer by layer
 One drain inserted, EVD maintained
DIAGNOSIS POST OPERATIF
Clinical Dx: Decrease of consciousness GCS 13 + Wound
dehiscence + Hemiparesis 
Etiology Dx : SOL intracranial post craniectomy tumor removal
Topic Dx : Temporoparietal sinistra
Additional Dx : Post External Ventricular Drainage
Post craniotomy debridement

Patient was treated in GICU

TRAUMA CASES
1. Yuda Putra Bakti / ♂ / 13 years old
Admitted on Wednesday, April 13th 2023 at 00.49 AM

ALLOANAMNESIS
Decreased of conciousness
Patient's parents complained their son fell from the motorbike. His
motorbike hit the car from left side then his head hit by a hard object.
Nausea (-), vomit (+), fever (-), seizures (+) 1 times shortly after
incident
History of helmet used (-)
(± 5 hours before admission)

PRIMARY SURVEY
A. Clear
B. RR : 22 x/mnt, SpO2 99%
C. PR : 98 x/mnt
BP : 120/70 mmHg
D. GCS : E3M5V3 : 11, isochoric pupils 3 mm/3 mm, Light
Reflex +/+
SECONDARY SURVEY
Cranium region
I : Hematome (+) of left parietooccipital region
P : Step off (+)
RADIOLOGY
Head CT Scan - Brain Window (M. Hoesin Hospital, 13-04-2023)
Left parietooccipital lobe EDH (Volume : ± 6.25 cc)
Cerebral oedema
RADIOLOGY
Head CT Scan - Bone Window (M. Hoesin Hospital, 13-04-2023)
Linear fracture of the left occipital bone
 MIST
M:
Patient's parents complained their son fell from the motorbike, then his
head hitting a hard object

I:
Cranium, cerebral

S:
Decreased of conciousness

T:
(-)
LABORATORY (M. Hoesin Hospital, 13-04-2023)
Hb : 14.9 gr/dl (12-16 gr/dl)
Ht : 43 vol % ( 40-48vol%)

DIAGNOSIS
Moderate head injury GCS 11 + Left parietooccipital lobe EDH +
Cerebral oedema + Linear fracture of the left occipital bone

MANAGEMENT
 Head up 30º
 O2 NRM 10 Lpm
 IVFD NaCl 0.9% gtt XX/m
 Inj. Ceftriaxone 1 gr/12 hours IV
 Inj. Paracetamol 1 gr/8 hours IV
 Conservative

Patient was treated in the Ward

NON TRAUMA CASES
1. Suhardi bin Nasron / ♂/ 67 Years old
Admitted on Wednesday, April 12th 2023 at 14.56 PM
ANAMNESIS
Pulsating mass in the abdomen
The patient complained of pulsating mass in the abdomen since 1 years ago.
The mass was getting bigger. There is no history of complaints of defecation.
Flatus (+). Nausea (-), vomiting (-), fever (-), pain, shortness of breath (-).
History of melena (-)
History of hypertension (+)
History of DM (-)
History of operation (-)

VITAL SIGN
Sens : Compos mentis
BP : 170/100 mmHg
HR : 94 x/m
RR : 22 x/m
T : 36,8 ºC
SpO2 : 99%
NPRS :5
PHYSICAL EXAMINATION

Thoraks Region
I : Symmetry +/+
P : Sonor +/+
A : Vesicular +/+
Rhonki (-), wheezing (-),
Heart sound I&II regular, Murmur (-),
Gallop (-)

Abdomen Region
I : Flat, pulsating supraumbilical mass (+)
P : Palpable solid pulsating mass fixed in
the supraumbilical, ± 15 x 12 cm,
tenderness (+)
P : Tympani
A : Bowel sounds (+)
RADIOLOGY
Rontgen of Thorax AP/PA (M. Hoesin Hospital, 12-04-2023)
RADIOLOGY
ECG (M. Hoesin Hospital, 12-04-2023)
Sinus rhythm
RADIOLOGY
USG of Abdomen (Sekayu Hospital, 11-04-2023)
dr. Meita Ranika, SpRad
Dilated abdominal aorta at the level of the umbilicus with a diameter of
± 4.32 cm and a length of 5.16 cm
Susp abdominal aortic aneurysm at the level of umbilicus
LABORATORY (M. Hoesin Hospital, 12-4-2023)
Hb : 14.8 gr/dl (12-16 gr/dl)
Ht : 43 vol % ( 40-48vol%)
WBC : 9.700 /mm3 (5000-10000/mm3)
Platelet : 297.000 /mm3 (150.000-450.000/mm3)
Albumin : 4.5 mEq/L (3.5-5.0 mEq/L)
BSS : 102 mg/dl (<200mg/dl)
Natrium : 138 mEq/L (135-155 mEq/L)
Kalium : 3.7 mEq/L (3.5-5.5 mEq/L)
Ureum : 60 mg/dL (16.6-48.5 mg/dL)
Creatinin : 1.64 mg/dL (0.70-1.20 mg/dL)
INR : 0.9
PT : 12.9 (kontrol : 15.10)
APTT : 30.5 (kontrol : 32.9)
Fibrinogen : 412 (kontrol : 271)
D-dimer : 2.04
Total cholesterol : 245 (<200
HDL : 64 (>55)
LDL : 178 (<100)
DIAGNOSIS
Abdominal aortic aneurysm + Stage II hypertension

Management
 IVFD NaCl 0.9% XX gtt/ m
 Inj. Paracetamol 1gr/ 8 hours IV
 Inj. Omeprazol 40mg/ 24 hours IV
 Thoraco-abdominal CTA with contrast

Management of Cardiologist Department

 Candesartan 8mg/24 hours PO
 Bisoprolol 2.5mg/24 hours PO
 Echocardiografi

Patient was treated in the ward

RADIOLOGY
CT Angiografi of Thoraco-abdominal (M. Hoesin Hospital, 13-04-2023)
2. Dahlan bin Basnan/ ♂ / 39 years old
Admitted on Wednesday, April 12th 2023 at 19.33 PM

ANAMNESIS
Right upper abdominal pain
Since ± 7 days before admission patient complained yellowish on his body,
nausea (+), vomit (-), fever (+), loss of appetite (+)
History of upper abdominal pain (+) since ± 2 weeks before admission
History of hospital care in Siti Khadijah Hospital and plan to MRCP
History of dark yellow urine (+)
History of pale stool (+)
History of hypertension and DM type II (-)
History of operation (-)

VITAL SIGN
Sens : CM
BP : 140/ 80 mmHg
HR : 78 x/mnt
RR : 20 x/mnt
T : 36.8 °C
NPRS :4
PHYSICAL EXAMINATION

Orbital region:
Icteric Sclera +/+

Abdominal Region
I : Flat (+)
P: Murphy sign (+)
P: Tympani (+)
A: Bowel sound (+)
RADIOLOGY
USG of Abdomen (Siti Khadijah Hospital, 11-04-2023)
Hydrops gallbladder
Dilatation of IHBD
LABORATORY (M. Hoesin Hospital, 12-04-2023)
Hb : 14.9 gr/dl (12-16 gr/dl)
Ht : 44 vol % ( 40-48vol%)
Leukocyte : 14.290 /mm3 (5000-10000/mm3)
Trombocyte : 385.000 /mm3 (150.000-450.000/mm3)
Ureum : 20 mg/dL (16.6-48.5 mg/dL)
Kreatinin : 0.9 mg/dL (0.70-1.20 mg/dL)
BSS : 114 mg/dL (<200mg/dL)
SGOT : 201 ( 0 – 38 )
SGPT : 524 ( 0 – 41 )
Total bilirubin : 5.7 mg/dl (0,1 – 1,0 mg/dl)
Direct bilirubin : 5.2 mg/dl (0 – 0,2 mg/dl)
Indirect bilirubin : 0.5 mg/dl (< 0,8 mg/dl)
Albumin :4 (3.4 – 4.8 )
Natrium : 135 mEq/L (135-155 mEq/L)
Kalium : 3.7 mEq/L (3.5-5.5 mEq/L)
PT : 12.1
APTT : 29.3
INR : 0.84
hsCRP : 2.7 mEq/L (< 5)
TOKYO Guideline 2018
TOKYO Guideline 2018
TOKYO Guideline 2018
DIAGNOSIS
Obstructive jaundice ec susp CBD distal obstruction + Moderate acute
cholangitis

Management
 IVFD Ringer Lactate gtt XX/ m
 Inj. Ceftriaxone 1gr/12 hours IV
 Inj. Metronidazole 500 mg/8 hours IV
 Inj. Metamizole 500mg/ 8 hours IV
 Inj. Omeprazol 40mg/ 24 hours IV
 Inj. Vit K 10mg/ 12 hours IV
 Pro. MRCP

Patient was treated in ward

THANK YOU