MORNING REPORT

THUESDAY, OCTOBER 13th 2021

Residents on duty :
ANS/AMI – AFA/AZY/DOS – GID
ZAM/GIR/KEN – BIM/TOS/GOR – FAL
ZET – ROD – WAL

Morning Report and Interdiciplines Group Coordinators:

1.Dr. dr. M. Bachtiar Budianto, SpB(K)Onk.
2.dr. Andhika Yudistira, SpOT(K).
3.dr. Paksi Satyagraha, M.Kes, SpU(K).
Visi & Misi RSUD dr. Saiful Anwar Malang
NILAI DASAR
Imam Ghozali/M/67yo/11519681
ToArr
Adm
: 10.00 WIB
: 10.10 WIB
AFTERNOON ADMISSION KST
PAS
General Status Diagnosis Problem Solving / Final Diagnosis
Time Problem
Management
10.10 Vital sign Patient was unable to urinate since 8 hours before admitted to the Working Dx: Planning Dx: - Other injury of urethra
GCS= 456 hospital. History of failed previous catheterization by emergency nurse in - Retention of urine - PSA and Testosterone (S37.39XA)
BP : 130/80 sub-urban hospital. History of LUTS (+) since 8 months ago. Patient was blood check - Urethral Stricture,
mmHg diagnosed with Lung TB since 3 months ago and planned for initial OAT Primary Dx: Unspecified (N35.9)
RR= 20x/min treatment in 18 October 2021 - Urethral Trauma Pars Treatment: - Malignant neoplasm
HR=80x/min History of operations : Bulbosa AAST gr III - Percutaneous of prostate (C61)
Tax : 36,6 C 1. TURP d.t BPH Retention in January 2019 Cystostomy - Tuberculosis of lung
BB : 60 kg 2. TURP Desobstruction + Bilateral Subcapsular Orchidectomy d.t Secondary Dx: - Consult to (A15.0)
TB : 165 cm Urinary retention and Prostate cancer cTxNxMx in March 2020 - Partial Urethral Pulmonologist for Lung - Retention of urine
BMI: 22 kg/m² Stricture Pars Bulbosa TB management (R33.9)
General St: - Prostate Cancer
Pulmo : Ves +/+, Rh +/+ Apex cTxNxMx on Surgical
ADT
Urology St: - Lung TB
R/ SP : Palpable 2 fingers below umbilicus
R/ GE: Male circumcised, Bloody meatal discharge +
Testis D/S : Not palpable Complication:
- Retention of urine
Thorax X-ray (06/10/2021)
- Fibroinfiltrat lesion on right suprahiler-paracardial -> Lung TB

Uretrography (13/10/2021)
- Extravasation of contrast at pars bulbosa
- Partial urethral stricture pars bulbosa
Imam Ghozali/M/67yo

Bloody Meatal Discharge

 Imam Ghozali/M/67yo

Extravasation of contrast at Fibroinfiltrat lesion on right

pars bulbosa suprahiler-paracardial
Jamik Anah/F/52yo/11519736
ToArr
Adm
: 12.00 WIB
: 12.05 WIB
AFTERNOON ADMISSION KST
PNT
General Status Diagnosis Problem Solving / Final Diagnosis
Time Problem
Management
12.05 Vital sign Patient referred from Wava Husada Hospital with susp of Left Renal Working Dx: Planning Dx: - Malignant neoplasm
GCS= 456 Tumor + Left Staghorn Stone post Bivalve Nephrolithotomy. Patient - Urosepsis - Blood and urine culture of kidney, except renal
BP : 120/90 complained of fever since 2 weeks before admitted to hospital and pelvis (C64.9)
mmHg getting worse for last 6 days. History of weight los 10 kg in last 2 months, Primary Dx: Treatment: - Sepsis, unspecified
RR= 24x/min Passive smoker (+) since 20 years ago. - Left Renal Tumor - Transfusion of PRC organism (A41.9)
HR=90x/min History of operations : cT4N1M0 - Transfusion of Albumin - Anemia, unspecified
Tax : 37,9 C 1. Left URS + DJ Stent Insertion in 16 July 2021 - Injection of Antibiotic (D64.9)
BB : 50 kg 2. Bivalve Nephrolithotomy in 11 August 2021 Secondary Dx: - Injection of Analgesic - Other disorders of
TB : 155 cm 3. Left DJ Stent Removal in 20 September 2021 (-) - Pro Left Radical plasma-protein
BMI: 20,81 kg/m² Nephrectomy if metabolism (E88.09)
General St: Complication: optimal condition
Anemis +/+ - Urosepsis
- Anemia
Urology St: - Hypoalbuminemia
R/ Flank S : Scar Post Op Lumbotomy 10x1cm in size. Palpable solid
mass, mobile, hard consistency, 8 x 5 cm in size, pain (-)

Laboratorium (13/10/2021)
CBC : 8,6/15.600/626.000
UL : pH 7/ BJ 1.020/ eri 538/ leuko 615
Alb : 2,25
Swab antigen: Negatif

Abdominal CT Scan with Contrast (11/10/2021)

- Left retroperitoneal mass, cystic, solid, 17,4 x 15 x 17,7 in size
Jamik Anah/F/52yo
 Jamik Anah/F/52yo

Left retroperitoneal mass, cystic, solid, 17,4 x 15 x 17,7 in size

MR. EFFENDI/M/70YO/11519657 ISS : 13
ToAcc : 06.00 RTS : 7.841
ToArr (Incovit) :
MORNING ADMISSIONS
PS : 99,3%
06.30
ToArr (Reguler) : 09.30 TAL,
ToCT : 10.00 YDI
ToAdm : 12.00
Time General Status Problem Diagnosis Problem Solving / Management Final Diagnosis
09.30 A : Patent Decrease consciousness Mild head injury Head elevation Concussion
B : Spontaneous Vomiting Oxygen supplementation (S06)
History of ORIF Humerus 30 years Subdural hygroma Fluid administration
symmetrical ago Bilateral Frontal region Analgetics Subdural hygroma
RR = 20 x/min Observation for VS, GCS, (S06.5)
C : HR = 88 x/min Laboratory Results CF distal third L clavicle seizures, lateralization and
BP =155/65 mmHg Leucocyte : 13.700 neer IIC Frontal lobe syndrome CF distal third L clavicle neer
D : GCS 356 Abs neutrophil : 8.6 Observation frontal lobe IIC
isochoric pupils Abs Lymphocyte : 3.99 Union R Proximal syndrome (AO 15.3AMT1 NV1)
3mm/3mm NLR : 2.16 Humerus post P-S
No lateralization Antigen swab : negative Proximal Humerus Neurosurgery Department : Union R Proximal Humerus
VAS: 4 - Non operative management post P-S Proximal Humerus
MOI : Chest X –Ray Saiful Anwar Vulnus Abration R - Head CT Evaluation if GCS Vulnus Abration R Forearm
Bicycle vs Hospital : Forearm decrease 2 point or there are (MT1 NV1)
motorcycle accident No fracture line frontal lobe syndrome
CF R Ankle Weber C Orthopaedic Department : CF R Ankle Weber C
Travelling history Head CT and Maxillofacial (AO43 A3 IC1 MT1 NV1)
(-) R Shoulder :
Saiful Anwar Hospital : - Armsling if mobilized
Contact history with Subdural hygroma R/L Frontal
COVID patient (-) - ORIF planned
region
Red zone area (-) No maxillofacial fracture R Forearm: Wound care
Today’s condition : No midline shift
GCS 456 R Ankle : Backslab
isochoric pupils
3mm/3mm
MR. EFFENDI/M/70YO
Clinical Appearance
MR. EFFENDI/M/70YO
MR. EFFENDI/M/70YO
MR. EFFENDI/M/70YO
 MR. EFFENDI/M/70YO
Chest X-Ray RSSA 13/10/2021

Union R Proximal
Humerus post P-S
Proximal Humerus
 MR. EFFENDI/M/70YO

- Site : R Clavicle
- Extent : Complete
- Configuration : Oblique
- Relationship of the fracture
fragment to each other :
Minimal displaced
 MR. EFFENDI/M/70YO

C1-C2 : 11 mm
C3-C4 : 11 mm
C5-C6 : 14 mm
 MR. EFFENDI/M/70YO

- Site : R Medial maleolus

- Extent : Incomplete
- Configuration : Transverse
- Relationship of the fracture
fragment to each other : Non
displaced

- Site : R Fibula
- Extent : Complete
- Configuration : Oblique
- Relationship of the fracture
fragment to each other : Non
displaced
 MR. EFFENDI/M/70YO
- Tibiofibular overlap : 2mm
- Medial clear space : 2mm
- Tibiofibular clear space : 2mm
MR. EFFENDI/M/70YO
Head CT RSSA 13/10/2021

Subdural hygroma R/L

Frontal region
MR. EFFENDI/M/70YO
Head CT RSSA 13/10/2021
MR. EFFENDI/M/70YO
MR. EFFENDI/M/70YO
MR. EFFENDI/M/70YO
MR. EFFENDI/M/70YO
MR. TUKIMAN/M/49YO/11519710 ISS : 18
ToAcc : 17.00 (11/10/2021) RTS : 7.841

EVENING OPERATIONS
ToArr : 10.20 (13/10/2021) PS : 99,3%
ToCT : 11.00 (13/10/2021) SPV : TAL, WMA
ToS : 22.00 (13/10/2021) Op/Ass : NAY/BRI-ZUL
Problem Solving /
Time General Status Problem Diagnosis Final Diagnosis
Management
10.20 A : Patent Referred from Bokor Hospital Mild head injury Head elevation Concussion
B : Spontaneous Headache and pain in the face Oxygen supplementation (S06)
symmetrical History of loss consciousness after Stitched wound frontal Fluid administration
RR = 21 x/min accident region Analgetic Open wound of head
C : HR = 77 x/min Stitched wound frontal region Human Antitetanus (SO1.9)
BP = 135/83 mmHg Bilateral Periorbital hematome Fr of R/L Maxilla non Immunoglobulin
D : GCS 456 Deformity of mandible lefort Observation for VS, GCS, Fracture of malar, maxillary
isochoric pupils Step off R/L rima orbita inferior seizures, lateralization and zygoma bones
3mm/3mm Step off R/L frontozygoma Fr of L Parasymphisis (SO2.4)
No lateralization Step off L arcus zygoma mandibular Neurosurgery
VAS;5 Step off R/L maxilla Department : Fracture of Mandible
MOI : Crepitation of R/L maxilla Fr of R/L ZMC Debridement (S02.6)
motorcycle vs motorcycle Unstable mandibula (86.28)
accident Trismus Fr NOE Type 1 Naso-orbital ethmoid
Laceration of palatum Primary closure (NOE) fracture
Travelling history (-) Fr of Palatum sagital type (88.81) (S02.2)
Contact history with 1
Laboratory Results
COVID patient (-) Plastic Surgery Open wound of head
Leucocyte : 13.840
Red zone area (-) Department : (S01.0)
Abs neutrophil : 10,44
Today’s condition : Abs Lymphocyte :2,49 Archbarr wiring
GCS 456 NLR : 4,19 (24.7)
isochoric pupils CRP : 8,37
3mm/3mm Antigen swab : Negative Plan for facial bone
reconstruction
(74.46)
MR. TUKIMAN/M/49YO/11519710 ISS : 18
ToAcc : 17.00 (11/10/2021) RTS : 7.841

EVENING OPERATIONS
ToArr : 10.20 (13/10/2021) PS : 99,3%
ToCT : 11.00 (13/10/2021) SPV : TAL, WMA
ToS : 22.00 (13/10/2021) Op/Ass : NAY/BRI-ZUL
General Problem Solving /
Time Problem Diagnosis Final Diagnosis
Status Management
Chest X –Ray Saiful Anwar Hospital : Mild head injury Head elevation Concussion
No fracture line Oxygen supplementation (S06)
Stitched wound frontal Fluid administration
Head CT and Maxillofacial Saiful Anwar region Analgetic Open wound of head
Hospital : Human Antitetanus (SO1.9)
No intracranial bleeding Fr of R/L Maxilla non lefort Immunoglobulin
Fr of R/L Frontozygoma Observation for VS, GCS, Fracture of malar, maxillary
Fr of L zygomatic arch Fr of L Parasymphisis seizures, lateralization and zygoma bones
Fr of R/L Sphenozygoma mandibular (SO2.4)
Fr of R/L Rima orbita inferior Neurosurgery
Fr of Dentoalveolar pars maxilla Fr of R/L ZMC Department : Fracture of Mandible
Fr of L Butress lateral maxilla Debridement (S02.6)
Fr of L Butress medial maxilla Fr NOE Type 1 (86.28)
Fr of L parasympisis mandible Naso-orbital ethmoid
Fr NOE type 1 Fr of Palatum sagital type 1 Primary closure (NOE) fracture
Fr of Palatum sagittal type I (88.81) (S02.2)
R/L Hematosinus maxilla
Fr of R/L Lateral sinus wall maxilla Plastic Surgery Open wound of head
Fr of R/L medial sinus wall maxilla Department : (S01.0)
Fr of R/L anterior sinus wall maxilla Archbarr wiring
(24.7)

Plan for facial bone

reconstruction
(74.46)
 TN. TUKIMAN/M/49YO
Clinical Appearance

Stitched wound frontal region Bilateral periorbital hematome

 TN. TUKIMAN/M/49YO
Clinical Appearance

Laceration of
TN. TUKIMAN/M/49YO
Clinical Appearance

Stiched wound frontal region

TN. TUKIMAN/M/49YO
Chest Xray Saiful Anwar (13/10/2021)
TN. TUKIMAN/M/49YO
Head CT Saiful Anwar (13/10/2021)
TN. TUKIMAN/M/49YO
Head CT Saiful Anwar (13/10/2021)
 TN. TUKIMAN/M/49YO
Head CT Maxillofacial Saiful Anwar (13/10/2021)
Fr of R/L anterior sinus
wall maxilla D/S

Fr of R/L Hematosinus Fr of R/L Lateral

maxilla sinus wall maxilla

Fr of R/L medial sinus

wall maxilla D/S
Fr of R/L
Sphenozygoma
TN. TUKIMAN/M/49YO
Head CT Maxillofacial Saiful Anwar (13/10/2021)
 TN. TUKIMAN/M/49YO
3D Head CT Saiful Anwar (13/10/2021)

Fr of L Arc zygoma Fr of Dentoalveolar pars

Fr NOE type Fr of R/L Rima orbita
maxilla inferior
1

Fr of L Butress medial Fr of L Butress lateral

Fr of L parasympisis Fr of R/L maxilla S maxilla S
mandibula Frontozygoma
 TN. TUKIMAN/M/49YO
3D Head Saiful Anwar (13/10/2021)

Fr. of Palatum
TN. TUKIMAN/M/49YO
Pre Operation
TN. TUKIMAN/M/49YO
Post Operation
TN. TUKIMAN/M/49YO
Post Operation
TN. TUKIMAN/M/49YO
Skull x-ray AP/Lateral
BG. AZAHIRA FARAH/F/8MO/7,5KG/11513913
ToArr : 14.50
ToCT : 15.50
ToAdm : 16.30
AFTERNOON TAL

Time

14.50
General Status

HR = 148x/min
Problem
ADMISSIONS
Patient’s mother felt her child didn’t respond as usual
Diagnosis

Working dx:
Problem Solving /
Management
Head elevation
Final Diagnosis

Communicating
RR = 48x/min while playing together, and her head seemed enlarged Hydrocephalus on R VP Oxygen suplementation hydrocephalus
GCS 456 History of underwent VP Shunt in June 2021 at Wava Fluid administration
Shunt Keen (G91.0)
BW : 7,5 Kg Husada Hospital Observation for VS, GCS,
Chamber VP Shunt in R Keen vomiting, seizures and
Primary dx:
Head Vena Dilatation (+) lateralization
Travelling History Head circumferrence : 47 cm Hydrocephalus on R VP
(-) Sunset phenomenon (+) Shunt Keen
Contact history with Crackpot sign (-)
COVID patient (-) Sunken eye (-) Secondary dx: Neurosurgery
Red zone area (-) Flat Fontanella (-) Department :
- Planning for Urgent L
Laboratory results Saiful Anwar : Complication dx: Revision of VP Shunt with
Leucocyte : 25.610 (-) low pressure, if the result
Abs Neutrophil : 14,36 of LCS Culture was sterile
Abs lymphocyte : 8,93 (02.34)
NLR : 1,61
Swab antigen : Negative - if it’s not sterile, plan for
take out the VP shunt then
Head CT (26/06/2021 Wava Husada hospital ) change to EVD insertion
Today’s condition: Severe Hydrocephalus (ER 0,68) (02.21)
GCS 456
Isocoric pupils - LCS analysis and culture
3mm/3mm Head CT (13/10/2021 Saiful Anwar Hospital )
Severe Hydrocephalus (ER 0,66)
Tip of vp shunt in ventricle on R keen point
BG. AZAHIRA FARAH/F/8MO/7,5KG
Clinical Appearance

Sunset phenomenon
(+)
BG. AZAHIRA FARAH/F/8MO/7,5KG
Head CT Wava Husada (13/10/2021)

Severe
Hydrocephalus, ER
0,68
BG. AZAHIRA FARAH/F/8MO/7,5KG
Head CT Saiful Anwar (13/10/2021)

Tip of VP shunt Severe

Hydrocephalus, A/B:
ER 0,66
BG. AZAHIRA FARAH/F/8MO/7,5KG
Head CT Saiful Anwar (13/10/2021)

Tip of VP shunt Severe

Hydrocephalus, ER
0,66
MR. BUNAMIN/M/60YO/11519748
ToArr
ToS
: 20.15
: 01.30
EVENING SPV : WAN, Suryanti
Op/Ass : IZI/YAR

Time General Status Problem OPERATIONS

Diagnosis Problem Solving / Final Diagnosis
Management
20.15 RR = 28 x/min Patient was referred from Working Dx : Oxygen Generalized peritonitis
BP = 90/60 mmHg Wonolangan Hospital with pain in Generalized peritonitis supplementation (K65.0)
HR = 116 x/min all area of the abdomen since a day Fluid administrations
Tax = 38,2°C ago Primary Dx : NGT and urine catheter Gastric perforation
GCS 456 Vomiting Generalized peritonitis insertion (K25.5)
qSOFA : 2 Fever dt Gastric Perforation Obs for VS and sign of
VAS = 4/10 History of consuming NSAID for the acute abdomen Pneumonia
2 months, because of pain in both Secondary Dx : CVC Insertion (J18.9)
legs Pneumonia Blood cultures
Travelling History Muscular rigidity (+) Biopsy of perforation Sepsis
(-) Complication Dx : side (A41.9)
Contact history Laboratory result Saiful Anwar Sepsis
with COVID Hospital 13/10/2021 Digestive Surgery
patient (-) Leucocyte : 17.540 Department :
Red zone area (-) Abs Neutrophil : 15,17 Exploratory laparotomy
Abs Lymphocyte : 1,29 (51.51)
CRP : 11,23
Procalcitonin : 85,97 Gastric repair`(Cellan
Anti SARS COV-2 : Negative Jones)
Chest X Ray : (44.6)
Infiltrate in R Lungs
Abdominal Xray : Join care with
Pneumoperitoneum Pulmonology
MR. BUNAMIN/M/60YO
Clinical Appearance
 MR. BUNAMIN/M/60YO
Chest X-ray initial Saiful Anwar (13/10/2021) Chest X-ray post CVC Saiful Anwar
(13/10/2021)

Infiltrate in lung
MR. BUNAMIN/M/60YO
Abdominal X-ray Saiful Anwar (13/10/2021)

Pneumoperitoneum
MR. BUNAMIN/M/60YO
DURING OPERATION

Gastric Perforation 1x1 cm

MRS. HENNI/F/60YO/11332802
ToArr
ToAdm
: 19.30
: 21.30 EVENING WAN, Yahya

Time General Status Problem ADMISSIONS Diagnosis Problem Solving /

Management
Final Diagnosis

19.30 RR = 26 x/min Intermittent pain of abdomen since 2 weeks Working dx: Fluid administration Malignant neoplasm of
BP = 175/113 mmHg Nausea Abdominal Pain Analgetics abdomen
HR = 94 x/min History being diagnosed with Abdominal Tumor Observation of VS and (C49.4)
Tax : 36,4°C in Persada Hospital since a week ago Primary dx: acute abdomen
GCS 456 History of decreased body weight 5kg in 3 months Tumor intraabdominal
susp GIST dd dermoid
DRE : TSA (+), mass (-), collapse of ampula recti cyst dd ovarian cyst
(-)
Travelling History (-) Secondary dx: Digestive Surgery
Contact history with Laboratory result Saiful Anwar : (-) Department :
COVID patient (-) Hb : 8,60 Tumor marker test
Red zone area (-) Abs Neutrophil : 3,42 Complication dx:
Abs Lymphocyte : 2,13 Anemia
Swab antigen : Negative
CEA : 1,39
CA 125 : 1234,00

Abdominal CT with contrast at Persada Join care with Obstetric

Hospital : and Gynecology
Dominant cystic mass between anus and rectum, Department
possibly left adnexa with attachment of intestine
(sigmoid, ileum) and anterior wall of rectum,
doubtful benign, size 9,7 x 7,8 x 8,4 cm
suggestive of ovarian cyst complex dd DD
Dermoid cyst DD GIST
MRS. HENNI/F/60YO
Clinical Appearance
MRS. HENNI/F/60YO
Chest X-ray Saiful Anwar (13/10/2021)
MRS. HENNI/F/60YO
Abdominal CT Persada Hospital (05/10/2021)

Lobullated et solid mass size 9,7 x 7,8 x 8,4 cm at

anterior rectum until L adnexa
MRS. HENNI/F/60YO
Abdominal CT Persada Hospital (05/10/2021)
MRS. HENNI/F/60YO
Abdominal CT Persada Hospital (05/10/2021)
MRS. HENNI/F/60YO
Abdominal CT Persada Hospital (05/10/2021)
MRS. HENNI/F/60YO
Abdominal CT Persada Hospital (05/10/2021)
MR. GUNAWAN/M/49YO/11519754
ToArr : 23.00 (13/10/2021)
ToAdm : 01.00 (14/10/2021) EVENING ADMISSIONS WAN

Problem Solving /
Time General Status Problem Diagnosis Final Diagnosis
Management
23.00 HR = 80 x/min Patient was referred from Persada Working Dx : Fluid administration Calculus of bile duct with
BP = 135/76 mmHg Hospital with pain in RUQ of the Mild cholangitis Analgetics cholangitis
RR = 20x/min abdomen since 2 weeks ago Antibiotics (K80.3)
Tax : 38,2°C Yellowish of the body and itchy for Primary Dx : Observation for VS and signs
GCS 456 1 week - Choledocholithiasis of acute abdomen
VAS 3/10 - Multiple Cholelithiasis
Icteric sclera (+/+)
Murphy sign (+) Secondary Dx : Digestive Surgery
Traveling history (-) (-) Department :
Contact history with Laboratory results Plan for
COVID patient (-) Leucocytes : 17.070 Complication Dx : Magnetic resonance
Red zone area (-) Absolute Lymphocytes : 2,13 Jaundice cholangiopancreatography
Absolute Neutrophil : 4,20 (88.97)
NLR : 1,97
RBG : 220 ERCP
Bil T/D/I : 9,65/9,63/0,02 (51.10)
Antibody SARS CoV : Negative
Laparoscopy explore CBD
Abdominal US : (51.0)
- Dilatation of IHBD and CBD
distal
- Cholelithiasis and slugde GB
- Hepatomegaly
MR. GUNAWAN/M/49YO
Abdominal US Gondanglegi Hospital (05/10/2021)

Multiple cholelithiasis with sludge gall

bladder
MR. GUNAWAN/M/49YO
Abdominal US Gondanglegi Hospital (05/10/2021)
BB. MRS.
INDRAWATI/M/1DO/3.320GR/11519752
ToArr
ToS
: 00.00
:
REMAINING WID, Astrid

Time
00.00
General Status
RR = 44 x/min
Problem
Referred from Mutiara Bunda
OPERATIONDiagnosis
Working Dx :
Problem Solving / Management
Oxygen supplementation
Final Diagnosis
Congenital absence, atresia,
HR = 140 x/min hospital without anus since birth Anorectal Malformation Fluid administration stenosis of anus without
Tax = 36,8°C (18.00 – 13/10/2021) OGT & Urethral catheterization fistula
Obs of VS, signs of acute abdomen (Q42.2)
Primary Dx : and VACTERL evaluation
Anus (-) Anorectal malformation
without fistula

Laboratory results Saiful Pediatric Surgery Department :

Anwar : Secondary Dx : Plan for tranversostomy
Traveling history (-) Leucocyte : 21.650 (-) (46.1)
Contact history Absolute Neutrophil : 15,42
with COVID patient Absolute Lymphocyte : 4,10
(-) NLR : 3,76 Complications Dx :
Red zone area (-) FH : 16,20/31,90 Prolonged FH
Procalcitonin : 0,34
Swab Antigen : Negative

Babygram X-ray AP/LL :

- Air distribution of intestine Join care with Pediatric Department
doesn’t reach pelvic cavity
- Dilatation of intestine

Knee Chest X-ray :

Distance between anal dimple and
intestinal air distribution about 2.3
cm
BB. MRS. INDRAWATI/M/0DO/3.320GR
Clinical Appearance
BB. MRS. INDRAWATI/M/0DO/3.320GR
Clinical Appearance

Anus (-)
BB. MRS. INDRAWATI/M/0DO/3.320GR
Babygram AP Saiful Anwar (13/10/2021)
BB. MRS. INDRAWATI/M/0DO/3.320GR
Knee chest Saiful Anwar (13/10/2021)
MR. SUCIPTO/M/66YO/11519755
SPV : TAL, ARI, Rodhiyan
ToArr
ToCT
ToS
: 22.00 (13/10/2021)
: 23.34 (13/10/2021)
: 06.00 (14/10/2021)
EVENING OPERATIONS Op/Ass : ZAM/ANS

Problem Solving /
Time General Status Problem Diagnosis Final Diagnosis
Management
22.00 HR = 102 x/min Decreasing consciousness starting from 15 Working dx: Head elevation Non traumatic ICH
BP = 177/82 mmHg hours before admission Decreasing consciousness Oxygen supplementation (I61.1)
RR = 20 x/min History of CKD for 3 years on HD for 4 Fluid administration
GCS 1x2 months Primary dx: Analgetics Hypertension
Isochoric pupil History of Uncontrolled hypertension for 10 CVA ICH in Brainstem Mannitol (I10)
3mm/3mm years Anticonvulsants
Lateralization (-) General seizures more than 5 times Secondary dx: Tranexamid acids Hydrocephalus
St II Hypertension Observation for VS, GCS, (G91.9)
Laboratory results Saiful Anwar : neurologic state, intracranial,
Travelling history (-) Leucocyte : 15.980 Complication Dx: pressure, seizures and
Contact history with Absolute Neutrophil : 14,44 Moderate hydrocephalus lateralization
COVID patient (-) Absolute Lymphocyte : 0,42
Red zone area (-) NLR : 34,38
Swab Antigen : Negative Neurosurgery Department :
R EVD kocher insertion
Chest Xray Saiful Anwar : (02.21)
Pneumonia
Tracheostomy
Head CT Saiful Anwar : (31.1)
Today condition: - CVA ICH Brainstem
GCS 1x1 - Moderate hydrocephalus (ER : 0,34)
Isochoric pupil - No midline shift
3mm/3mm Join care with Neurological
Department
MR. SUCIPTO/M/66YO

Thorax Xray Saiful Anwar (13/10/2021)

 MR. SUCIPTO/M/66YO
Head CT Saiful Anwar (13/10/2021)

CVA ICH
Brainstem

Hydrocephalus
MR. SUCIPTO/M/66YO
Head CT Saiful Anwar (13/10/2021)
Mr. EH/M/30 YO
ToAcc : 23.00 (1 day ago) ISS : 1
ToArr
ProcStart
: 15.30 WIB
: 17.00 WIB AFTERNOON ADMISSION RTS : 7.8408
PS : 99.61 %
ProcEnd : 18.00 WIB

Time General Status Problem Working Problem Solving / Final Diagnosis

Diagnosis Management
15.30 A : Patent Pain and open wound on the L hand Vulnus laceratum Analgetic Vulnus laceratum
B : Clear, spontan palmar side L hand Antibiotic palmar side L hand
symmetrical, RR Local state Human tetanus (MT1 NV1)
20x/mnt, SpO2 99% L Hand : immunoglobulin
on room air L : Vulnus laceratum (+) palmar
C : HR 70 x/mnt, BP side, size 2cm x 0,5cm subcutis - Debridement
122/84 mmHg, CRT based, swelling (+), yellowish serous - Primary closure
< 2 sec discharge (+)
D : GCS 456 pupil F : Tenderness (+), warm (+), NVD
isochoric, diameter (+) normal
3mm/3 mm, light M : ROM limited dt pain
reflex (+/+), Active MCP thumb flexion : 0-20⁰
lateralization (-) Active MCP thumb extension : 0-5⁰

VAS score : 2-3/10

MOI : Injured by a
rusty scissors

Swab antigen :
negative
Travelling history (-)
Contact history with
COVID patient (-)
Red zone area (-)
Malang
Mr. EH/M/30 YO
Mr. EH/M/30 YO
Mr. EC/M/31 YO
ISS : 5
ToAcc : 4 days ago
RTS : 7.8408
ToArr
ProcStart
: 20.30 WIB
: 21.00 WIB EVENING ADMISSION PS : 97.65 %
DPJP Utama : dr. YD
ProcEnd : 22.00 WIB
DPJP Pendamping : dr. TAL

Time General Status Problem Working Problem Solving / Final Diagnosis

20.30 A : Patent
B : Clear, spontan
symmetrical, RR 20x/mnt,
SpO2 98% on room air
C : HR 86x/mnt, BP 131/76
mmHg, CRT < 2 sec
D: GCS 456 pupil isochoric,
diameter 3mm/3 mm, light
reflex (+/+), lateralization (-)
VAS score : 4-5/10
MOI : Motorcycle in collision
with another motorcycle
Swab antigen : negative
Travelling history (-)
Contact history with COVID
patient (-)
Red zone area (-)
Kelutan, Trenggalek
Diagnosis Management
Pain and swelling on head, pelvis and R lower leg Mild head injury 456 Analgetic Mild head injury 456
Antibiotic
Local state Subluxation R hip joint dt bony Subluxation R hip joint dt bony
Pelvis : fragment entrapment post closed Neurosurgery Dept : fragment entrapment post closed
L : Swelling (+) reduction of CF dislocation R hip - Nonoperative reduction of CF dislocation R hip
F : Tenderness (+) NVD (+) normal joint thompson & epstein type IV management joint thompson & epstein type IV
Vertically & rotationally stable (AO 62-B1.3 IC1 MT1 NV1)
CF R head femur Orthopaedic Dept :
R Thigh : R Hip : CF R head femur
L : Swelling (+) CF inferior R ramus pubis - Skin traction (AO 31-B1 I C1 MT1 NV1)
F : Tenderness (+), NVD (+) normal incomplete - Plan for open
M : ROM limited reduction, removal of CF inferior R ramus pubis
Active Hip flexion & extension : 0° CF R fibula segmental isolated bony fragment & incomplete
internal fixation (AO 62-A1 IC1 MT1 NV1)
Appearent length : 97/97 cm Vulnus laceratum anterior side R
True length : 87/87 cm lower leg R Lower leg : CF R fibula segmental isolated
Anatomical length : 40/40 cm - Debridement (AO 4F2-A3 IC1 MT1 NV1)
LLD : 0 cm - Primary closure
- Backslab Vulnus laceratum anterior side R
R Lower leg : lower leg
L : Swelling (+), vulnus laceratum (+), anterior (MT1 NV1)
side, sized 3x1 cm, subcutised based
F : Tenderness (+), NVD (+) Normal
M : ROM limited
Active Ankle dorsoflexion : 0-5⁰
Active Ankle plantarflexion : 0-10⁰
Mr. EC/M/31 YO
Mr. EC/M/31 YO
 Mr. EC/M/31 YO
(Initial X-Ray Pre Closed Reduction)

- Site : R acetabulum
- Extent : Complete &
intraarticular
- Configuration : Comminutive
posterior wall + tranverse
fracture acetabular floor
- Relationship of the fracture
fragment to each other :
Displaced fragment posterior
wall + dislocation of R head
femur

- Site : L inferior ramus pubic

- Extent : Complete
- Configuration : Oblique
- Relationship of the fracture
fragment to each other : Non
displaced
 Mr. EC/M/31 YO
Post closed reduction
Mr. EC/M/31 YO
Mr. EC/M/31 YO
Mr. EC/M/31 YO
 Mr. EC/M/31 YO
Post closed reduction
- Site : R femur
- Extent : Complete &
intraarticular
- Relationship of the fracture
fragment to each other :
Displaced
 Mr. EC/M/31 YO
- Site : R fibula
- Extent : Complete
- Configuration : Oblique
- Relationship of the fracture
fragment to each other :
Displaced
Mr. EC/M/31 YO
Mr. EC/M/31 YO
Mrs. MU/F/53 YO
NON-TRAUMA PATIENT EVENING ADMISSION
ToArr : 23.50

Time General Status Problem Working Problem Solving / Final Diagnosis

Diagnosis Management

23.50 Moderately Ill Patient was referred from Lavallete Hospital Pathological Fracture Vert - Analgetic Pathological Fracture Vert
complaining about pain on lower back since Lumbal II-III FR E Dt Lumbal II-III FR E Dt
Vital sign : 5 months previously. The pain getting MBD Process Ca - Inline Mobilization MBD Process Ca
GCS: 456 worsen in this 2 weeks. The patient’s Mammae - Pain Management Mammae
BP : 148/95 mmHg mobility became limited because of the pain. - Tumor marker
N : 87 x/mnt Patient’s thigh feels like being squeezed. - Bone survey
RR : 20x/mnt Pain is continuous and worsen when the - Usg Abdomen
Tax : 36.3 C patient changed his position such as from - Plan for transpedicular
sitting to standing. Pain radiate to right biopsy
lower leg and right foot - LSO
- Consult to oncology
Laboratorium Micturition and defecation is in normal limit surgery dept
(12/10/2021) :
Hb : 14,0 g/Dl History of fever, chronic cough, and
WBC : 8.390/mcL shortness of breath denied
Platelet: 279,000 History of night sweat denied
U/L History of tauma denied
LED: 22 mm/jam History of TB denied
History of Weight loss (+) 5 kg in past
ALP : On Process month
LDH: On Process
CRP : 0,51 mg/dl *Past Medical History*
History of myoma uteri that had operated in
2014
History of left breast mass, patient went to
Antigen Swab : alternative treatment
Negative
Traveling history (-) Localized status
Contact history with Back Region:
COVID patient (-) L: Gibbus (-)
Red zone area (+) F: tendernes (+)
Mrs. MU/F/53 YO
NON-TRAUMA PATIENT AFTERNOON ADMISSION
ToArr : 23.50

Time General Status Problem Working Problem Solving / Final Diagnosis

Diagnosis Management

Neurologic State
Motoric :
C5 elbow flexor 5/5
C6 wrist extensor 5/5
C7 elbow extensor 5/5
C8 finger flexor 5/5
Th1 finger adductor 5/5

L2 hip flexion 5/5

L3 knee extension 5/5
L4 ankle dorsoflexion 5/5
L5 great toe extension 5/5
S1 ankle plantar flexion 5/5

Sensoric :
L1 2/2
L2 2/2
L3 2/2
L4 2/2
L5 2/2
S1 2/2

Reflex fisiologis :
Patellar tendon reflex +2/+2
Achilles tendon reflex +2/+2

Reflex patologis :
Babinski -/-
Caddock -/-
Hoffman -/-
Tromner -/-

TSA (+)
PAS (+)
BCR (+)
Mrs. MU/F/53 YO
NON-TRAUMA PATIENT AFTERNOON ADMISSION
ToArr : 23.50

Time General Status Problem Working Problem Solving / Final Diagnosis

Diagnosis Management

NOMS Framework :
- Neurological: ESCC : 1C
- Oncologic : Radiosensitive (Ca Mammae)
- Mechanical : SINS = 11 (potentially
unstable)
- Systemic : No Systemic problem
 OUTPATIENTS
NO NAME DIAGNOSIS COMMENTS

1 MS. DINI YULIASTUTI/F/27YO/11519739 INSECT BITE L FOOT REGION DISCHARGED

ZULFADELI MAULANA MULTIPLE VULNUS ABRASSION R

2 DISCHARGED
F/M/7YO/11519744 ANTEBRACHII REGION DT CAT SCRATCH

3 MR. JASMAN/M/64YO/11519745 CONTUSIO MUSCULORUM R CHEST REGION REFUSED TO ADMISSION

MS. DEWI MEISITA AYU MILD HEAD INJURY + SAH + CEPHAL

4 REFUSED TO ADMISSION
LESTARI/F/20YO/11519746 HEMATOME L PARIETAL REGION
THANK YOU
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