Case Report, Monday, April 7th 2014

Team on duty :

dr. Andria Saputra dr. M. Nazir Tambunan dr. Rynaldi Andriansya dr. Sumrahadi Manurung dr. Khalikul dr. Jauhari Deslo Angkasa Wijaya dr. Muharriansyah

No 1 3 4

Distribution of surgery patient Emergency room patient Out of clinic Refuse medical advice

Room

Total 6 Patients 1 Patients 5 Patients

/961912 2 Hospitalize

Jeumpa 3 Jempa 1 Jempa 2

Nur Ainun/46 yo/F/Dx. Ca. Mammae Sinistra End Stage + Ulcus Decubitus + Multiple Site Bone Metastase + Anemia/ POD 6/COD : End Stage

5 6

Passed away Hospitalize room

28/28 bed 28/28 bed

Jempa 3
Jempa 4

28/28 bed
28/28 bed

No

Distribution of surgery patient

Room
ICU

Total
3 Patients

HCU NICU
PICU

2 Patients 4 Patients
2 Patients

ICU

1. Azhari Ilyas/ M/ 23 yo/Dx. Contusion ICH temporal grade III + SDH Temporal/Tx. Craniotomy Evacuated/POD 2 2. Muchtar Ubit/M/62 yo/Dx. Stroke Haemorraghic + ICH a/r Fronto Temporal + Hydrochepalus/Tx. Craniotomy Evacuated ICH/POD 6 3. Elli Fitria/ F/28 yo/Dx. Effusion Pleura Dextra + Pneumonia/Tx. Post WSD/POD 4

HCU

1. Ismanidar/F/30 yo/Dx. Perforation Jejunum + Resection Anastomosis with Stapler + Haematothoraks dextra/Tx. Laparatomy Eksploration/POD 7 2. Khairil Anwar/M/46 yo/Dx. Chest Pain + Dyspneu/Tx. Angiography/POD 1

PICU

1. Laili Huda Haki/ 13 yo/ F/Dx. Post Laparotomy Eksploration + Adhesiolisis + Ileal Resection + Redo Iileostomy ec Ileal Anastomose Leakage Post Redo Ileostomy + Primary Suture Ileal Perforation ec Abdominal Burst due to Appendix Perforation/Tx. Debridement/POD 3 2. M. Mirza/M/7 yo/Dx. Combutio 30% Grade II-III with Inhalation Trauma + Compartment Syndrome/Tx. Debridement + Fasciotomi/POD 2
5

NICU

1. By Ida khairuna/G/9 do/Dx. Hydrochepalus Congenital/AD 6 2. By Yenita /G/11 do /Dx. Hydrocephalus/Tx. Vp Shunt/POD 5 3. By Tristiana/M/17 do / Re-laparatomy exploration + resection anastomose + ileo ileal and repair perforation jejunum / POD 11 4. By Fitriani/G/ 8 do /Dx. Malformation Anorectal High Level Without Fistel/Tx. Colostomy Divided/POD 5

Patient identity
: Dika Mauliza : 15 years old : Boy : Kp Mulia, Kec. Syiah Kuala, Banda Aceh MR : 99 75 13 Driving License : (-) Phone number : 081362611337 Patient came at : 06.36 PM Name Age Sex Address

Chief complaint Decrease of consciousness Patient illness History The patient came to Zainoel Abidin emergency room with decrease of consciousness for 1 hour. The complaint started when the patient was riding motorcycle without helmet and suddenly strucked by another motorcycle from beside of him. There was history of vomiting.. There was no trauma at the other part of body..

Physical examination
Primary Survey A: Clear B: Spontaneous, RR: 20 breaths/ minute C: BP : 130/80 mmHg Pulse: 70 beats/minute D: GCS: E3 M6 V4 GCS 13, isochoric pupil 3 mm/ 3 mm, light reflex (+/+)

L/S at the right temporal region L : swelling (+), wound(-)

Secondary Survey There was no trauma at other part body

Assessments: Moderate head injury

Management
Stop oral intake Head up 300 Oxygen 2 litre / minute via canule IVFD NaCl 0,9% 20 drips/minute Inj. Ceftriaxone 1 gr Inj. Metamizol sodium 1 gr Laboratory examination Radiology examination

Laboratory result
Hb White blood count Platelet Ht CT BT Blood glucose ad random : : : : : : : 15,5 gr/dl 16.400/ul 290.000 /ul 46 % 6 minute 2 minute 133 mg/dl

Radiology result
Head CT-Scan : There was SCALP hematoma at the left ocipital region There was no fracture at the bone window Sulcus and gyrus was narrow There was hyperdense biconvex area at the right temporal base region EDH Ventricle and cysterna system was narrow There was no midline shift

Diagnose: Moderate head injury + EDH at the right temporal base region

Consult to Neurosurgery Division : Craniotomy evacuation EDH emergency

Operative report
Patient in supine position, head up 30o and turn to the left with general anesthesia. Performed aseptic and antiseptic procedure Performed reverse question mark incision until bone Performed 3 Burr hole, bone was sawed with gigly and pulled out Identified EDH with thick 3 cm Performed dura hit stiches and evacuated the EDH 30 cc Bleeding control Bone was return Performed one tube drain Closure the wound by primary suture

Post Operative Diagnosed Moderate head injury (ICD 10 CM S09.9) + EDH at the right temporal base region (ICD 10 CM S06.4)

Follow Up
Date S O VS/ BP : 110/ 70 mmHg Pulse: 88 beats/mnt RR: 20 breaths/minute GCS : E4 M6 V5 pupil isochoric Temp 36,7oC A Moderate head injury (ICD 10 CM S09.9) + EDH at the right temporal base region (ICD 10 CM S06.4) P Diet 1800 Kcal Head up 30o IVFD NaCl 0,9% 20 drips/minutes Ceftriaxone inj 1g/12 hours Metamizol sodium inj 1 g/8 hours 11/4/2014 Pain POD IV (-)

Patient identity
Farid Wajdi 34 years old Male Blang Oi, Kec. Meuraxa, Banda Aceh MR : 99 74 93 Phone Number : 085260875584 Patient came at : 02.01 PM Name Age Sex Address : : : :

Chief complaint Pain at the right lower abdomen Patient illnes History Patient came to Zainoel Abidin emergency room with a chief complaint pain at the right lower abdomen since 6 hours ago. Initially, patient felt pain at epigastric region and then pain was remain at the lower right abdomen. History of fever and vomiting was present.

Physical examination
Vital sign :
Blood Pressure Pulse Respiratory rates Body temperature : 110/70 mmHg : 100 beats/min : 22 breaths/min : 36,7 oC

L/S at the right lower abdominal region :

I : Symmetrical, distension (-) A: Bowel sound (+) P: Pain at McBurney sign (+) P: Thympani (+)

Digital rectal examination Tonus Spinchter ani: Tight Rectal Ampulla : Faeces (+) Rectal Mucous : Smooth Pain : (+) Glove : Faeces(+)

Assessments: Acute Appendicitis

Management
Stop oral intake IVFD RL 20 drips / minute Inj. Ceftriaxone 1 gr Inj. Ketorolac 30 mg Laboratory examination

Diagnosed Acute Appendicitis

Consult to pediatric surgery division Appendectomy emergency

Operative report
Patient in supine position with general anasthesia A and Antiseptic procedure and then drapping procedure Performed Grid iron incision Incision was deepened layer by layer until found peritoneum Direct exploration to caecum Identified caecum, appendix antecaecal, erectil, oedem, length 7 cm and without perforation Appendix was release from mesoapendix with antegrade and bleeding controlled. Performed appendectomy and double ligation sutured Operation area irrigated with normal saline until surely clean Operation wound closed by primary suture

Post Operative Diagnosed Acute appendicitis (ICD 10 CM K35.2)

Follow Up
Date S O Vital Sign : General condition: good BP : 120/80 mmHg RR : 18 breaths/mnt Pulse : 78 beats/mnt L/S at the right lower abdominal region : I : Symmetrical A: Bowel sound (+) P: Pain (-) P: Tympani (+) A Acute appendicitis (ICD 10 CM K35.2) P Outclinic patient . 10/4/2014 Pain (-) POD III