Morning Report

Monday, January 6th 2020

Team On Duty
dr. Aulia Rahman (Chief)
dr. Yudi Nugraha (Jaga 1)
dr. Saddam Husein Damanik (Jaga 1)
dr. Rachditia Ichwiyantho (Jaga 1)
dr. Teuku Zulbahraini (Jaga 2)
dr. Nanda Subhan (Jaga 2)
dr. Rendi Thantawi (Jaga 3)
dr. Wirya Hartanto Danu P (Jaga 4)
dr. Adista Umar (Jaga 5)
RSUDZA
No. Distribution of surgery patient Room Total
1 Emergency Room Patient 24 Patients
2 Hospitalize 16 Patients
3 Out of Clinic 8 Patients
4 Refuse Medical Advice 0 Patients
ICU D M. Tsaqif Rahmatillah/11yo/respiratory failure, CKD on CAPD, shock
5 Passed Away hypovolemic due to active bleeding
PICU
6 Hospitalize Room Raudhah 1 20/28 bed
Raudhah 2 25/28 bed
Raudhah 3 26/28 bed
Raudhah 4 25/28 bed
Raudhah 5 22/28 bed
Raudhah 6 27/29 bed
Raudhah 7 25/29 bed
ICU D 3 Patients
ICU C 2 Patient
ICCU 0 Patient
PICU 1 Patient
NICU 3 Patient
 ICU ADULT • Ainol mardhiah/69yo/Ivh due to stroke hemorrhagic post vp shunt/POD 19
• Ainsyah Ismail/61yo/post craniectomy evacuation of SDH/POD 10
• Ibram Hasyem/51yo/ stab wound ar colli sinistra, pneumothorax sinistra, post VATS/
POD 4
ICU CARDIAC • Alfian Irwan/24yo/post craniectomy bifrontal evacuation ICH ar. Frontal/ POD 2
• Fandy Osa/ 33yo/ post VP shunt ai hidrocephalus non communican due to ICH ar.
Basal Ganglia/ POD 1
ICCU -

PICU • Muhammad Habibi/4yo/Relaparotomy explorasi ec. Diffuse peritonitis due to

leakage anastomosis/ POD 2

NICU • By. Ny. Lindyani/18do/Hirschprung Disease/AD 16

• By. Ny. Sabrina Saffa/29do/Hirshcprung Disease/AD 8
• By. Ny Maulizar Agus/4 do/atresia ani with fistel perianal post minimal PSA/ POD 3

#
Patient identity
• Name : Rusmawati A. Tumino
• Age : 49 years old
• Sex : Female
• Address : Kec. Bandar Baru, Pidie Jaya
• MR : 1-23-36-36
• Mobile Phone : 085260228296
• Admission time : 05.00 PM
• Driving license : (+)
 Time Response
Date/hour Examinati Laboratory Radiology Hour of Date/hour
patient came on hour Examination Examination Diagnostics patient out DPJP
to ER from ER
Send Result Send Result

6th Jan 2020 05.10 PM 05.30 06.30 06.00 06.30 06.30 PM 6th Jan 2020 dr. Yopie A
05.00 PM PM PM PM Hospitalize H, Sp.BTKV
PM
Chief complaint
• Pain at the chest after trauma

Patient illnes History

• The patient was referred from Tgk. Abdullah Syafii
Beureunun district hospital to Zainoel Abidin Hospital
with a chief complaint pain at the chest after trauma
for 8 hours.
• Initially the patient was driving a motorcycle and
accidently he strucked with another motorcycle from
opposite and hit the aspalt.
• The patient also complained of pain in the facial and
right shoulder
• There was no history decrease of consciousness,
• There was no history nausea & vomiting.
• Eyes opened spontaneously, motoric obeys
commands, verbal good orientations.
Physical examination
Primary survey :
• A : clear
• B : spontaneous, RR: 24 breaths/minute Sp02 : 97%  4
L/minute (via nasal canule)
Right hemithorax Left hemithorax

Inspection Asymetrical, trachea midline, JVP in normal limit

Palpation Emphysema Subcutaneous (-) Emphysema Subcutaneous (-)

pain (-) pain (+)
Percussion Sonor Dullnes

Auscultation Vesicular , Vesicular decreased

Rh (-), Wh (-) Rh (+), Wh (-)

• C : BP : 130/90 mmHg, Pulse : 102 beats/minute, IVFD RL 1500

cc/24 hours , catheter urine 80 cc
• D : GCS: 15 (E4 M6 V5), Isocoric Pupil, Light reflect (+/+)
•E
L/S at the facial region
Upper face
L : Symmetrical, excoriated wound (-), swelling (-), hematoma (-)
F : Pain (-), step off (-)

Middle face
L : Asymmetrical, excoriated wound (-), swelling (-),
hematoma (+) at the left lower palpebral
F : Pain (+), step off (+)
Visus OD  2/2 - OS  2/2
Movement of eyes  in normal limit
Lower face
L : Asymmetrically, swelling (+), hematoma (-), excoriated
wound (-)
F : Pain (+), step off (+)

Intra Oral:
Malocclussion
• Open bite (+)
• Dental loose (+)
• Alveolar Floating (-)
• Maxilla Floating (-)
• Lacerated wound (-)
• Secondary survey
Head & neck
L/S at the facial region
Upper face
L : Symmetrical, excoriated wound (-), swelling (-), hematoma (-)
F : Pain (-), step off (-)
Middle face
L : Asymmetrical, excoriated wound (-), swelling (-), hematoma (+) at
the left lower palpebral
F : Pain (+), step off (+)
Lower face
L : Asymmetrically, swelling (+), hematoma (-), excoriated wound (-)
F : Pain (+), step off (+)
Intra Oral:
Malocclussion
• Open bite (+)
• Dental loose (+)
• Alveolar Floating (-)
• Maxilla Floating (-)
• Lacerated wound (-)
 Thorax :

Right hemithorax Left hemithorax

Inspection Asymetrical, trachea midline, JVP in normal limit

Palpation Emphysema Subcutaneous (-) Emphysema Subcutaneous (-)

pain (-) pain (+)
Percussion Sonor Dullnes

Auscultation Vesicular , Vesicular decreased

Rh (-), Wh (-) Rh (+), Wh (-)

Abdomen : in normal limit

Pelvic : in normal limit
Upper extremity : in normal limit
Lower extremity : In normal limit
Assessments:
1. Susp Hematothorax at the left hemithorax due to
blunt thoracal injury with stable hemodinamic
2. Susp fracture left maxilla
3. Susp fracture mandible
4. Dental lose
Management
• Head up 30 °
• Inj. Ceftriaxone 1 g
• Inj. Ketorolac 30 mg
• Laboratory examination
• Radiology examination
Laboratory result
• Hb : 12,0 gr/dl
• White blood count : 13.400 /ul
• Platelet : 206.000 /ul
• Ht : 29 %
• CT : 7 second
• BT : 2 Second
Radiology result
Thorax AP:
• Tracheal in midline possition
• There was bronchovasculare appereance until lateral
• There was discountuinity at the 2nd, 3rd, 6th, 7th , 8th
anterior ribs of the left hemithorax
• The left costophrenicus angle was blunt
• Discontinuity of right clavicle
Head CT Scan 3D reconstruction:
• There was discontinuity at the lower of the left
orbital rims
• There was discontinuity maxilla bilateral
• There was discontinuity at the left condile mandible
• There was discontinuity at the corpus mandible
• discontinuity of right zygoma arch
• There was discontinuity of right maxilla
• Dental lose at the incicivus 1,2 and caninus at the
right side of the maxilla
Diagnose:
1.Fracture at the lower of the left orbital rims (ICD 10 CM SAX 10)
2.Fracture maxilla bilateral (ICD 10 CM S02.09)
3.Fracture at the left condile mandible (ICD 10 CM S20 AX)
4.Fracture at the corpus mandible (ICD 10 CM S02.69)
5.Susp hematothorax at the left chest due to blunt thoracal injury
with stable hemodynamic (ICD 10 CM J94.2)
6.Fracture at middle right clavicle (ICD 10 CM SX 10S)
7.Fracture costae at the 2nd, 3rd, 6th lateral ribs and 7th , 8th posterior
ribs of the left hemithorax (ICD 10 CM S22.2)
8.Dental lose at the incicivus 1,2 and caninus at the right side of the
maxilla
Planning:
Consult to Thorax cardiovascular surgery division
• Insertion left Chest tube
• Hospitalized
• Platting costae elective

Consult to plastic surgery division

• ORIF elective

Consult to orthopedic surgery division

• Arm sling
• ORIF clavicula elective
Operative report:
• Incision at linea mid axillaris anterior at left inter
costae space 5th with local anesthesia
• Inserted chest tube 28 FR  air bubble (-) undulation
(+) blood 400 cc
• Chest tube was fixated with nonabsorable 1.0
Post operative diagnose:
1.Fracture at the lower of the left orbital rims (ICD 10 CM SAX 10)
2.Fracture maxilla bilateral (ICD 10 CM S02.09)
3.Fracture at the left condile mandible (ICD 10 CM S20 AX)
4.Fracture at the corpus mandible (ICD 10 CM S02.69)
5.Susp hematothorax at the left chest due to blunt thoracal injury
with stable hemodynamic (ICD 10 CM J94.2)
6.Fracture at middle right clavicle (ICD 10 CM SX 10S)
7.Fracture costae at the 2nd, 3rd, 6th lateral ribs and 7th , 8th posterior
ribs of the left hemithorax (ICD 10 CM S22.2)
8.Dental lose at the incicivus 1,2 and caninus at the right side of
the maxilla
Post Insertion left chest tube
 Follow up :
Date S O A P

January 8th Pain (+), General Condition Post operative diagnose:  Oxygen 4 L/minute (via canule)
2020 decrease. Vital Sign : 1.Fracture at the lower of the left  IVFD RL 20 drips/minutes
Blood pressure : 130/90 mmHg orbital rims (ICD 10 CM SAX 10)  Inj. Cefuroxime 1 g/12 hours
POD 1 HR : 90 beats/minute 2.Fracture maxilla bilateral (ICD 10
RR : 22 breaths/minute  Inj. Ketorolac 30 mg/8 hours
CM S02.09)  Diet liquid
Raudah 6 SpO2 98 % 3.Fracture at the left condile
NRS 3 mandible (ICD 10 CM S20 AX)
4.Fracture at the corpus mandible Planing
(ICD 10 CM S02.69) Ct scan Thorax
Right hemithorax Left hemithorax 5.Susp hematothorax at the left Plating costae elective
Inspection symetrical, trachea midline, JVP in normal limit chest due to blunt thoracal injury ORIF clavicle
Chest tube : undulation(+), bubble (-), production with stable hemodynamic (ICD 10 ORIF maksilofascial
(-) CM J94.2)
Palpation Emphysema Emphysema 6.Fracture at middle right clavicle
Subcutaneous (-) Subcutaneous (-) (ICD 10 CM SX 10S)
pain (-) pain (+) 7.Fracture costae at the 2nd, 3rd, 6th
Percussion Sonor Sonor lateral ribs and 7th , 8th posterior
ribs of the left hemithorax (ICD 10
Auscultatio Vesicular , Vesicular CM S22.2)
n Rh (-), Wh (-) Rh (-), Wh (-) 8.Dental lose at the incicivus 1,2
and caninus at the right side of
the maxilla
Post Insertion left chest tube