Morning Report Wednesday May 6nd, 2015

RSUDZA

Team on duty

dr. Hendra Kastiaji ( Jaga I )

dr. Rynaldi Andriansya (Jaga II )

dr. Muharriansyah (Jaga III)

dr. Sumrahadi Manurung ( Jaga III)

dr. M. Reza ( Jaga IV )

dr. Adang Sunandar ( Jaga IV)

dr. Herdi Gunanta S. ( Jaga V )

Dr. Asri (Jaga V)

/961912No Distribution of surgery patient Room1 Emergency room patient Patients2 Hospitalize Patients3 Out of clinic Patients4 Refuse medical advice -5 Passed away6 Hospitalize room Jeumpa 1 28/28 bed

Jeumpa 2 28/28 bedJeumpa 3 28/28 bedJeumpa 4 28/28 bed

ICU 7 PatientsHCU 1 PatientsPICU 2 PatientsNICU 5 Patients

3

ICU ADULT 1. M Yunus/M/60 yo/Post Craniectomy ec ICH + SDH/ POD 82. Hadijah/ F/52 yo/ snake bite + Abdominal hypertension/ POD 113. Sunardi/M/32 yo/ Post Open Reduction Cervical 5-6 Frankle A/POD 64. Laili/F/42 yo/post craniektomi evacuation ICH + SDH/POD 45. Yusmaniah/F/37 yo/Post op Craniotomy Removal tumor + Vp shunt ec.

Hidrocephalus non communican /POD 16. Timakah Shaleh/F/70 yo/Post op Craniotomy Evakuasi EDH/POD 47. Sugeng Wijono/M/24 yo/ Post op repair arteri carotis sin + arteri Temoral superficial

sin/ POD 1

NICU 1. Noval Hanif/M/6 days/Meningoensefalokel/AD 102. Khanza/M/5 days/Post VP Sunt ec Hidrocephalus /POD 83. Siti Fatimah/F/4 days/Post VP Shunt ec Hidrocephalus + meningocele/POD 74. Rosmawati’s Baby/M/6 Days/Suspect oesofageal Atresia Post Gastrostomy/ POD 35. Fitri Rahmawati I and Fitri Sakinah II/F/ 3 days/ Konjoint Twin Craniophagus/ AD 3

HCU 1. Siti Idarwati/F/20 yo/Dx. Post op Craniotomy EDH Evacuatiion /POD 52. Ismail/M/53 yo/Dx. Pos op Total Tyroidectomyec. Tyroid Ca Intra Thoracal / POD 1

PICU 1. Marlinda’s Baby/M/2 Mo/dx. Post Op Repair Shunt ar. Peritonial + Post Vp Shunt ec Hydrochepalus+Bronkhopneumonia+Diare Akut/POD 13

2. M. Abdul Matin/M/4mo/dx. Post op Colostomy Closure/AOD 5

Patient Identity

• Name : sudirman• Age : 22 years old• Sex : Male• Address : lampakuk kuta cot glie• CM : 1050939• HP : 081269977400• Admission time : 06.00 PM

Time ResponseDate/hour

patient came to

ER

Examination hour

Laboratory Examination

Radiology Examination

Hour of Diagnostic

s

Date/hour

patient out from

ER

Send Result Send Result

Mei 6st 2015

06.00 PM

06.50 PM 07.00 wPm

08.00PM

07.15PM

08.15PM

08.30 PM

11.00PM inapropriat

e

Chief Complain: Pain and difficulty to move right foot

Present illness history

The patient came to Zainoel Abidin Emergency room with a chief complain pain and dificulty to move the right foot for 8 hours. The complain started after his leg hit by block of wood when he was working. There was no trauma at other patr of body.

Physical examination Primary Survey • Airway : Clear• Breathing : Spontan, 18 breaths/min • Circulation : Blood Pressure: 110/80 mmHg, Pulse: 88

beats/min• Disability : GCS E4M6V5 = 15• Exposure :

At regio right ankle :L : Lacerated wound 11x 4 x 1 cm (+), deformity (+) internal rotation,

haematom (+), bone expose (+) F : Pain (+), NVD (-)

M : ROM limited

Right foot Finger

SpO2

I 100 %

II 98 %

III 98 %

IV 97 %

V 99 %

Secondary surveyHead & Neck : in Normal limitThorax : in normal limit Abdomen : in normal limit Genitalia : in normal limitUpper extremity : in normal limitLower extremity :

At regio right ankle :L : Lacerated wound 11x 4 x 1 cm (+), deformity (+)interna rotation,

haematom (+), bone expose (+) F : Pain (+), NVD (-)

M : ROM limited

Right foot Finger SpO2

I 100 %

II 98 %

III 98 %

IV 97 %

V 99 %

• VAS : 5

Assessment1.Dislocation at the right ankle joint2.Open fracture of the cuboid of the right tarsal

Management

• Stop oral intake• IVFD RL 20 drips/min• Inj. Cefazoline 1 gr • Inj. Ketorolac 30 mg• Inj. Tetagam 250 IU• Laboratory examination• Radiology examination

Laboratory result• Hemoglobin : 11,6 gr/dl • White Blood Count : 14.600 /ul• Platelets : 217.000/ul• Hematocrit : 33 %• CT/BT : 7’/3’

Radiology result

Right Pedis AP/oblique• There was dislocation ankle joint • There was fracture of the cuboid ao the tarsal

Diagnose 1. Dislocation at the right ankle joint2. Open fracture of the cuboid of the right

tarsal

Consult to Orthopaedic surgery• Debridement and OREF emergency

Operative report• Refreshening edge wound, necrotomy, corpus

alienum removal• Performed insertion stainmann pins from medial

to lateral tibia, calcaneus and metatarsal II• Fixation with wire and acrylic

Post Diagnose 1. Dislocation at the right ankle joint (ICD-10-

CM M25.279)2. Open fracture of the cuboid of the right

tarsal (ICD-10-CM M25.279)

Follow UpDate S O A P

8/5/15POD II

Pain (+)

Blood pressure 120/80 mmhg Pulse 86 beats/minute RR 20 breaths/minute

S/L at the right leg regionL : sweeling (+), capilary reffil (+). F : pain (+)NVD (-) M: ROM limited

Dislocation at the right ankle joint (ICD-10-CM M25.279)

Open fracture of the cuboid of the right tarsal (ICD-10-CM M25.279)

IVFD RL 20 drips/minInj Cefazoline 1 gr/12 hrsInj.Ketorolac 30 mg/ 8 hour

Patient identity

• Name : Zaini• Age : 64 years old• Sex : Male• Address : Sibreh, Aceh Besar • Phone Number : 08123706418• MR : 1050898• Admission time : 11.46 AM

Time ResponseDate/hour

patient came to

ER

Examination hour

Laboratory Examination

Radiology Examination

Hour of Diagnostic

s

Date/hour

patient out from

ER

Send Result Send Result

Mei 06st 2015

11.46 AM

12.00 AM 12.45 PM 14.00 PM

13.30 PM

14.30 PM

01.00 PM 09.00 PM Non apropriate

Chief complainPain and difficulty to move at the left hand

Patient illnes historyPatient came with a chief complain pain and difficulty to move at the left hand since 5 hours ago. Initially, patient repair cow stall at his farm, suddenly he fell and his left hand hit and cutting by a thin plate roof. There was history of active bleeding at the wound. There was no decrease of conciousness.

Physical examination• Airway : Clear • Breathing : spontaneus, 20 breaths• Circulation : Blood Pressure: 135/90 mmHg, Pulse: 90

beats/min.• Disability : GCS 15

• Exposure :L/S at the left hand region :– L : active bleeding (+), lacerated woud 6x2x1,5 cm, pale.– F : pain (+), parestesia. NVD (+) allent test (+) radial and

ulna artery– M : ROM limited left wrist joint

SPo2 :

Hard Sign Soft Sign

Pulsatile bleeding (+) Significant hemorrage history (+)

Expanding Hematom (+) Diminished pulse contra lateral (++/-)

Distal ischemic (+) Neurology abnormality (-)

Bruit (-) Fracture (-)

Digiti 1 Digiti 2 Digiti 3 Digiti 4 Digiti 5

84% 90% 87% 87% 85%

• VAS : 6

Assessments: 1.Susp. Rupture a. Radialis and a. Ulnaris of the

left hand2.Rupture tendon flexor digitorum at the left

hand

Management• Stop oral intake • Bleeding control pressure gauze bandage• IVFD RL 2000 cc / 24 hours• Inj Cefazoline 1 gr • Inj Ketorolac 30 mg• Laboratory examination• Radiology examination

Laboratory result• Hb : 12,5

gr/dl • White blood count : 18.400 /ul• Platelet : 212.000 /ul• Ht : 42 %• CT / BT : 7` /2`

Radiology result

Antebrachii AP/L• There was no discontinuity of bone

Diagnose

1. Susp. rupture a. Radialis and a. Ulnaris of the left hand

2. Rupture tendon flexor digitorum at the left hand

Consult to Vascular surgery division• Exploration and repair vascular emergency

Consult to Orthopaedic division• Exploration and repair tendon emergency

Operative report • There was total rupture of the a.radialis and a.

Ulnaris• Performed trombectomy and anastomosis • There was rupture tendon flexor digity superficial, flexor digity profunda, flexor carpi

radialis and nervus medianus. • Performed repair tendon and nerve and

imobilization palmar flexion with back slab and kleinert procedure

Post Operative Diagnose 1.Rupture A. Radialis and a. Ulnaris of the left

hand (ICD-10-CM S53.20) (ICD-10-CM S53.3)2.Rupture tendon flexor digitorum

superficial ,flexor digiti profunda, flexor carpi radialis at the left hand (ICD-10-CM M66.31)

3.Rupture n. medianus at the left hand (ICD-10-CM M66.10)

Follow up

Date S O A P

08-05-15POD II

Pain (+) 

Vital sign BP : 120/80 mmHgPulse : 84 beats/mnt RR : 20 breaths/mnt

S/L at the left hand : L: F:M :

Spo2 :

Rupture A. Radialis and a. Ulnaris of the left hand (ICD-10-CM S53.20) (ICD-10-CM S53.3)

Rupture tendon flexor digitorum superficial ,flexor digiti profunda, flexor carpi radialis at the left hand (ICD-10-CM M66.31)

Rupture n. Medianus at the left hand (ICD-10-CM M66.10)

IVFD RL 20 drip/minute Inj. Ceftriaxone 1 gr/12 hour Inj Ketorolac 30 mg/ hour Inj Metronidazole 500 mg/8 hour

Diet 1800 kcal

Digiti 1 Digiti 2 Digiti 3 Digiti 4 Digiti 5

95% 90% 94% 92% 95%

Patient Identity

• Name : Sugeng• Age : 25 years old• Sex : Male• Address : Desa Siti amba, Aceh Singkil• CM : 105-08-13• HP : 085260967402• Admission time : 08.10 AM

Time ResponseDate/hour

patient came to

ER

Examination hour

Laboratory Examination

Radiology Examination

Hour of Diagnostic

s

Date/hour

patient out from

ER

Send Result Send Result

Mei 6st 2015

08.10 AM

08.15 AM 08.20 AM

09.30 AM

9.45 9..55 09.00 AM 9.45 apropiriate

Chief Complain: Masive bleeding at the left neck

Present illness history

The patient referred from Kesdam hospital to Zainoel Abidin Emergency Room with a chief complain masive bleeding at the left neck for 5 hours ago. The complain started after the patient passenger of a car and strucked a truck from opposite. There was history of decrease consciousness, nausea and vomiting.

Physical examination Primary Survey • Airway : Clear , with c-spine control• Breathing : already performed ETT , 18 breaths/min on ventilator• Circulation : Blood Pressure: 75/50 mmHg, Pulse: 130 beats/min performed ressuscitation.• Disability : GCS cannot examination, isochoric pupil, light reflex

(+/+) • Exposure :

L/S Neck region (zone 3) :L : Lacerated wound 7 x 2 x 1 cm (+), active bleeding (+),

haematom (+),F : Pain (+), pulse (+) carotis artery Performed control

bleeding with gauze.

Hard Sign Soft Sign

Pulsatile bleeding (+) Significant hemorrage history (+)

Expanding Hematom (-) Diminished pulse contra lateral

Distal ischemic (-) Neurology abnormality (+)

Bruit (-) Fracture (-)

Zone neck

L/S at the left auricula L : Lacerated wound (+) , 4 x 3 x 1 cm , hematom (+), partial rupture of a.temporal superficialisF : Pain (+)

Abdomen : I : distensi (+) minimal,

hematom (-)A : Bowel sound (+), pain (+)P : Soepel (+)P : Tympani (+), liver dullness (+)

Secondary surveyHead & Neck : L/S Neck region (zone 3) :

L : Lacerated wound 7 x 2 x 1 cm (+), active bleeding (+), haematom (+),

F : Pain (+), pulse (+) carotis artery.

L/S at the left auricula L : Lacerated wound (+) , 4 x 3 x 1 cm

, hematom (+), partial rupture of a.temporal superficialisF : Pain (+)

Thorax : in normal limit Abdomen :

I : distensi (+) minimal, hematom (-)A : Bowel sound (+), pain (+)P : Soepel (+)P : Tympani (+), liver dullness (+)

Genitalia : in normal limitUpper extremity : in normal limitLower extremity : in normal limit

Assessment1.Hipovolemic shock grade 3 with transient

response due to rupture artery of the left neck

2.Blunt abdominal injury3.Lacerated wound at the left auricula

Management

• Stop oral intake• IVFD double line resuscitation crystaloid 2000 cc + 500 cc

colloid • Maintenance 2100 cc / 24 hours patient unstable

hemodynamic transient response exploration and bleeding control at the operation room

• Inj. Cefotaxime 2 gr• Inj. Ketorolac 30 mg• Inj. Tetagam 250 IU• Laboratory examination

Laboratory result

• Hemoglobin : 6,4 gr/dl

• White Blood Count : 20.600 /ul• Platelets :

97.000/ul• Hematocrit : 38 %• CT/BT

: 7’/3’

Diagnose 1.Hipovolemic shock grade 3 with transient

response due to rupture artery of the left neck2.Blunt abdominal injury3.Lacerated wound at the left auricula

Consult to Vascular surgery division:• Exploration and repair vascular emergency (source

control)Consult to Digestive surgery division:• Performed FAST on operation room (+)

accumulation fluid at the left spleenorenal • Performed DPLConsult to Plastic surgery division:• Reconstruction left auricula

Operative report• TCV division

There was rupture and performed repair ruptured of the left a.facialis, of the left a.transversalis and of the left superficial temporal artery

• Digestive divisionDPL (-), there was no blood and enteric contain.

• Plastic divisionReconstruction auricula

Post Operative Diagnose1. Hipovolemic shock grade 3 with transient

response due to rupture of the left a.facialis, of the left a.transversalis and of the left superficial temporal artery (ICD-10-CM R57.1) (ICD-10-CM I72.8)

2. Rupture solid organ (ICD-10-CM C83.39) 3. Lacerated wound at the left auricula (ICD-10-

CM S01.00)

Follow UpDate S O A P

8/5/15POD 2

On ventilator SIMV 02 35%

General condition Blood pressure 130/80 mmhg Pulse 86 beats/minute RR: 18 breaths/minute suport ventilator, SIMV, FiO2 35%

S/L at the right leg regionL : Performed anterior slab wound operation dry F : NVD (-) M: ROM limited

Hipovolemic shock grade 3 with transient response due to rupture of the left a.facialis, of the left a.transversalis and of the left superficial temporal artery (ICD-10-CM R57.1) (ICD-10-CM I72.8)

Rupture solid organ (ICD-10-CM C83.39)

Lacerated wound at the left auricula (ICD-10-CM S01.00)

IVFD RL 20 drips/minInj Cefazoline 1 gr/ 12 hourInj.Ketorolac 30 mg/ 8 hour

Terapi ICUfentanyl 30mgprofpofol 100mgnorepinefrin 0,2mg

Patient identity

•Name : Ilham Saputra•Age : 14 year old•Sex : Boy•Address : Blangtuphat timur,

lhokseumawe•Father’s phone : 082367376827•MR : 1050943•Admission time : 04 50 AM

Time respond

Date/Time patient came to ER

Examination hour

Laboratory Examination

Radiology Examination

Time of Diagnostics

Date/Time patient out from ER

Send Result Send Result

5/05/201504.50 AM

05.00 05.15 06.30 06.15 07.00 07.15 12..30 AM Inapropiate

Chief complaint•Decrease of conciousness Patient illnes history•Patient referred from district hospital Kesrem to Zainoel Abidin emergency room with a chief complaint decrease of conciousness after trauma for 1 day. Patient was passenger motorcycle without helmet with his sister. Suddenly the patient strucked by another motorcycle from behind, and fell off to the aspalt. History alert after trauma (-), nausea and vomite (+)

Physical ExaminationPrimary Survey :•A : Clear, c spine control•B : Spontaneous, RR: 22 breaths/ minute•C : Pulse: 94 beats/minute, BP : 120/70 mmhg•D : GCS: 10 (E2 M5 V3) ; isochoric pupil 3 mm/3mm, no lateralization, light reflex (+/+) •E : L/S at the right parietal region

L : excoriated Wound (+) 3x5cm, Hematoma (+)

F : Pain (+), discontinuity of bone (+)

Secondary survey

L/S at the right parietal regionL : excoriated Wound (+) 3x5 cm, Hematoma (+)F : Pain (+), discontinuity of bone (+)

Neck : In normal limited

Thorak : In normal limited

Abdomen : In normal limited

Pelvis : In normal limited

Lower limb : In normal limited

Assessment : •Moderate Head Injury •Susp. Fracture depress at the right parietal region

Management•Stop oral Intake•Head up 30°•Oxygen 7 l/i via facemask •IVFD Normal saline 0,9 % drip 20/mnt•Inj. Ceftriaxone 1g / 12 hour•Inj. Keterolac 30 mg/ 8 hour•Laboratory examination •Radiology examination

Laboratory result•Hemoglobin : 10 gr/dl •White blood count : 16.400/ul •Platelet : 186.000 /ul •Hematocrite : 19 %•CT : 8 minute •BT : 2 minute •Blood Glucose ad random : 118 mg/dl

Radiology resultHead CT-Scan :•There was subgaleal haematoma at the right fronto parietal region•There was depressed fracture at the right parietal region•Sulcus and gyrus was narrow•Ventricle system was normal•Cysterna system was narrow•There was midline shift to the left > 0,5cm

Diagnose 1.Moderate Head Injury (ICD-10-CM S09.8) 2.Fracture depressed at the right parietal region (ICD 10 CM SO2)

Consult to Neurosurgery Division•Craniotomy emergency elevasi fracture depress

Intra Operative•Incision question mark •Found a thick epidural hematoma was about 1/2 cm –Evacuated EDH and bleeding control, with

volume ± 10 cc–Performed elevation depress fracture

Post Op Diagnosed1.Moderate Head Injury (ICD-10-CM S09.8) 2.Fracture depressed at the right parietal

region (ICD 10 CM SO2) 3.EDH at the right parietal region(ICD 10 CM

S06.4)

Follow Up

Date S O A P

8-05-2015POD II

(-)  Pulse: 86 beats/minuteRR: 20 breaths/ minuteGCS: (E2 M5 V3) ; isochoric pupil 3 mm/3mm, no lateralization, light reflex (+/+)

 

Moderate Head Injury (ICD-10-CM S09.8)

Fracture depressed at the right parietal region (ICD 10 CM SO2)

EDH at the right parietal region (ICD 10 CM S06.4)

IVFD NaCl 0,9 % 20 gtt/ 24 hrs

Inj. Ceftriaxone 1 amp/12 hrs

Inj. Paracetamol 75mg/8 hour

Ondancentron 1 amp/12 hr

Ranitidin 1 amp/12 hr

Patient identity•Name : Muhammad Hasan•Age : 68 years old •Sex : Male•Address : Bayu, Aceh Utara•CM : 105 0965•Phone : 085360474747•Admission time : 01.50 AM

Time Response

Date/Time patient

came to ER

Examination hour

Laboratory Examination

Radiology Examination

Time of

Diagnostics

Date/Time

patient out

from ER

Send Result Send Result

5/0/201501.50 AM

02.00 02.15 03.30 03.15 04.00 02.00 10.20 PM

Inappropiate

Chief complaint•Decrease of consciousness Presenting history of illness•The patient was referred from Lhokseumawe district hospital to emergency room Zainoel Abidin hospital with a chief complaint decrease of consciousness since 2 weeks ago. previously the patient slipped and fell off at his home and he was admitted at the hospital for two days. There was no history alert after trauma, nausea and vomiting

Physical examinationPrimary survey :A : ClearB : Spontaneous, RR: 20 breaths/ minute,C : Pulse 85 beats/minute, Blood Pressure:

140/80 mmHg D : GCS : E3M6V5 : 14; isochoric pupil, Ø

3mm/ 3mm no lateralization, light reflex (+/+) E : L/S ar dextra temporal region :

L : hematoma (-), oedema (-), exoriated wound (+)

F : Pain (-), discontiunity of bone (-)

Assessments: •Mild head injury

Management•Head up 30 0

•Stop oral intake•IVFD NaCl 0,9 % 20 drips/minutes •Inj. Ceftriaxone 1g •Inj. Ketorolac 30mg•Laboratory examination •Radiology examination

Laboratory result•Hb : 13,7 gr/dl •White blood count : 12,800/ul•Platelet : 238.000 /ul•Ht : 44 %•CT : 7 minute•BT : 2 minute •Blood glucose : 113 mg/dl

Radiology resultHead CT-Scan :• Scalp hematome (-)•Sulcus and gyrus was narrow•There was hypodens and hyperdense abnormal at the right frontoparietal region Subdural hemorrage•Ventricular system narrow•Cysterna in normal limit•Midline shift to the left > 0,5 cm

Diagnose : 1.Mild head injury2.Chronic Subdrural hemorrage

Consult to Neurosurgery Division :•Burr hole evacuation hemmorage

Operation Report •Made 2 burr hole at the parietal region•Evacuation blood cloth 20 cc•Left 2 pen drose

Post Operative diagnose •1.Chronic Subdrural hemorrage (ICD CM 10 S06.5)•2.Mild head injury (ICD 10 CM S09)

Foto intra op

Follow upDate S O A P

8-5-2015POD I

Pain (+)

GCS : E3 M6V5Isochoric pupil Ø 3mm/3mmBP :130/90 mmHgHR : 80 beats / mntRR : 20 breaths/mnt

Sl. Right ParietalL : gauze dryF : Pain (-)

1.Chronic Subdrural hemorrage (ICD CM 10 S06.5)2. Mild head injury(ICD 10 CM S09)

Head up 30 0

IVFD RL 20 drips / minutesInj. Ceftriaxon 1g/12 hours Inj. Ketorolac 3% 30 mg /8 hours Inj. Ranitidine 150 mg/12 hours