Monday, 5th June 2017

In Emergency Installation, we received 18 patients, consist of :

1. Laceration wound (T.14.1) : 2 pts Wound toilet + suturing + Amoxicilin
+ Mefenamic Acid discharged
2. Mild head injury GCS E4M6V5= 15 (S09.90XA), segmental fracture of
right corpus mandibula (S02.6)), multiple excoriation wound on facial -
neck region cb traffic accident 1 days before admission (T14.0) : 1 pt
Oxigenation + head up 300 + Observation + wound toilet + barrel fixation +
Ceftriaxone inj. + Ketorolac. inj + Ranitidin. inj + pro reconstruction of
facial bone elective MRK 1
3. Mild head injury GCS E4M6V5= 15 (S09.90XA), minimal ICH on right and
left frontal region cb traffic accident : 1 pt (I61.9) Oxigenation + head up
300 + Observation + Ketorolac. inj + Ranitidin. inj + manitol inj R5A
4. Mild head injury GCS E3M6V5= 14 (S09.90XA), SAH (S06.6),
uncomplicated close fracture of 1/3 middle of left clavicle compelete
(S42.002P), malunion fracture of right clavicle, fracture of the 3rd & 4th left
posterior rib cb traffic accident 12 hours before admission (S42.001P) : 1 pt
Oxigenation + head up 300 + Observation + Manitol inj + Ketorolac. inj +
Ranitidin. inj + pro ORIF elective R2B
5. Communicans hydrocephalus (G91.0) : 1 ptHead up 300 + pro VP shunt
electiveC1L1
6. Compression fracture of 5th lumbal-1st sacral vertebrae cb felt from
height 1 year before admission (S34.105): 1 pt pro laminectomy
decompression electiveMRK1
7. Wound dehiscence post laminectomy 1 month ago cb Herniated
Nucleus Pulposus VL1-2 (T81.4XXA): 1 ptpro MRI elective +
repair wound dehiscence MRK2
8. Paravertebral abscess of 9th-11th Thoracal vertebra cb spondilitis
TB: 1 pt (G06.1) pro laminektomi dekompresi elective + drainage
abscess + joint management with internist R3B
9. Meningoencephalocele (Q01.9) : 1 pt pro MSCT
Craniocerebral PBRT
10. Uncomplicated close fracture of 1/3 middle of right clavicle oblique
displaced (S42.001A), hemangioma supraglotis post tracheostomy 1
week ago (D18.0): 1 ptketorolac inj + arm sling application + pro
ORIF elective + joint with ENT departement (pro excision) transit
11. Intra abdominal tumor extra luminer T3N0M0 (D21.4), Anemia
(D64.9) : 1 pt PRC transfusion R5A
12. Hematoscezia with internal hemoroid grade III (K62.5) , anemia (D64.9) :
1 pt PRC transfusion KTL
13. Generalize peritonitis cb perforated jejunum diverticle (K65.0), sepsis
(A41.9) Congestive Heart Failure grade IV cb severe mitral stenosis
(I50.23) , jaundice (R17): 1 pt ciprofloxation inj + metronidazole inj +
rehydration + Diagnostic Peritoneal lavage + exploratory laparotomy +
joint management with cardiology departement ICU
14. Acute limb ischaemic cb Arterial Occlusive Disease of right leg (I73.9),
Sepsis (A41.9), Adeno ca cervic TxN2M1 liver st.IV (C53.9)
embolectomy + joint management with Obsgyn departementGRD 5
15. Invasive lobular carcinoma of left breast,2nd Grade, T4aN1M1 (bone)
st.IV post chemotherapy 4x, External Radiation 32x (C50.112), anemia
(D64.9), moderate dehidration : 1 ptPRC transfusion +
rehydrationTransit
16. Invasive ductal carcinoma of left breast 3rd grade T4cN0M1 (lung)) st.IV
(C50.012), anemia (D64.9): 1 pt PRC transfusion R2A
17. Urinary retention cb prostate enlargement (R33.9) : 1 pt urethral
catheter application discharged
Monday, 5th June 2017
CASE REPORT (13.05)
A 40 years old male came to Emergency Installation referred from Suwondo Pati
Hospital with chief complaint pain on his whole abdomen.
Chief complain : pain on whole abdomen

History of Illness :

+ 3 months before admission, patient complaint of bloating and eye yellow, he is no

complaint defecate and urin. Patient easily tired
+ 3 weeks before admission, patient complaint his body yellow defecate blackish
brown, dark yellow urine. Patient still complaint of bloating, no improvement with
medication
+ 6 days before admission, Patient complaint of abdominal pain on his upper stomach.
Patient looks yellowish. Patient said that the pain existed all day and the pain is worsen
when his stomach is being press,cough and after each meal. Patient was taken to RS
soewondo pati and also complaint shortness of breath, black coloured stool,worsen
abdominal pain. Patient was treated in icu for 6 day then he was reffered to RSDK
+ 1 day before admissions patient felt pain on all area of the abdomen, nausea vomit
(+), fever (+) defecation and fart (-). Patient was brought to because lack of facility then
patient referred to Kariadi hospital
History of Pass ilness : Heart Diseases (-), hepatitis (-)
History of long time analgetic consumption (+)
History of traditional medicine consume (+)
Physical Examination :
General Condition : look weak
Vital sign :
RR : 28 x/mnt
PR : 132 x/mnt
BP : 79/47 mmHg ( MAP : 59 )
t : 38,6 C
VAS : 4

Head/Neck : - conj. palp yellow

- sclera icteric
- shrunken eyes +/+
- forehead skin turgor decreased
- dry lips (+)
- JVP wasnt increase
Chest :
Heart :
I : IC cannot be seen
P : IC palpable on ICS VII, 2 cm lateral LMCS
P : Configuration widen to the left
A : murmur (+)
Lungs :
I : Simetric on static and dinamic
P : Stem fremitus equal left and right
P : Sonor whole area
A : Basic sound vesicular, additional sound (-)

Abdomen : I : dome shaped, skin color same as surrounding

Pa: tenderness on all area, defance muscular (+)
P : Hypertympanic, liver dullnes (-)
A : bowel sound (+)
Extremities : Upper Lower
cyanosis -/- -/-
cold acral -/- -/-
cap refill <2/<2 <2/<2

D.R.E : Adequate anal sphincter tone, smooth mucous, no

mass/tumor, ampula recti was not collapse, tenderness (+) on
all area
Glove : stool (+) dark, mucous (-), blood (-)
External genitalia: male, inserted urethral catheter 16 Fr yellowish clear
(180 cc/4 hours = 0,9 cc/kg/hour);
Intraabdominal pressure = 15 cm H2O = 10,5 mmHg
X-Thorax AP (Suwondo pati hospital: 29-5-2017)
Echocardiography (Suwondo Pati)

Working Diagnose (08.55):

- Generalized peritonitis cb hollow viscous perforation suspected gaster
DD/ Duodenum
- Sepsis
- Severe dehydration
- Congestive heart Failure NYHA IV cb Severe Mitral Stenosis
- jaundice DD/ post hepatal

11
Initial Management (13.35) :
- IpDx :
S:-
O : thorax x-ray, plain abdominal x-ray
- IpTx :
O2 10 lpm NRM
CVC insertion CVP 4 cm H2O
Rehydration program
Infus RL 200 dpm ( 6 hours )
Inserted NGT 16 Fr initial production 10cc brownish
Maintain urethral cathether
Inf. Ciprofloxacin 400 mg/12 hrs intravenous
Inf Metronidazole 500mg/8 hrs intravenous
Inj Tramadol 50 mg/8 hrs intravenous
Inj Ranitidine 50 mg/ 12 hrs intravenous
Joint with cardiology deparment
Pro Peritoneal drainage

- IpMx :
Complaint, general condition, vital sign, Routine blood, electrolite, and coagulation study,
GDS, Ureum, Creatinin, BGA artery, BGA mixed vein, Lactate, ECG, urine output, CVP,
blood culture
- IpEx :
Informed consent : Diagnosis, surgical treatment, prognosis.
Laboratorium (15.22):
Hb : 12,9 gr % (13 16 gr%)
Ht : 39,9 % (35 47 %)
Lekosit : 9.32 /mmk (3,6 11 rb/mmk)
Tromb : 233 /mmk (150 400 rb/mmk)
PPT/K : 30,8 /10.3dtk (11,1 12,4 dtk)
APTT/K : 119,4 /33.2 dtk (32,3 33,1 dtk)
GDS : 87 mg/dL (80 140 mg/dL)
Ur : 178 mg/dl (15 39 mg/dl)
Cr : 1,7 mg/dl (0,5 1,5 mg/dl)
Na : 138 mmol/l (136 145 mmol/L)
K : 4,7 mmol/l (3,5 5,1 mmol/L)
Cl : 105 mmol/l (98 107 mmol/L)
SGPT : 207 u/L (15-60 u/L)
SG0T : 59 u/L (15-34)
Bilirubin total : 24,57 mg/dL (0,3-1,2)
Bilirubun Direk : 20,16 mg/dL (0,0-0,2)
Arterial BGA (15.40)
pH : 7.409 (7,37-7.45)
FiO2 : 32 %
pCO2 : 28,7 mmHg (35-45)
pO2 : 41,8 mmHg (83.0-108.0)
HCO3 : 18,3 mmol/l (18-23)
TCO2 : 19,2 mmol/l
BE : -13,6mmol/l ( -2 3)
O2 Sat : 99,4% (95-100)
Mixed vein BGA (14.20)
Scvo2 : 59,9%
Lactate : 2,0 mmol/L

ECG : septal old miocard infark

Chest x-ray
Plain abdominal
1
2
2
1

0
0

2
0
0

0
0
0
5
17
Apache II score :
Score : 17 mortality rate 25 %

Interpretation score

Score Death Rate (%)

0-4 4

5-9 8

10-14 15

15-19 25

20-24 40

25-29 55

30-34 75

>34 80
Working Diagnose (15.55):
- Generalized peritonitis cb hollow viscous perforation suspected gaster
DD/ Duodenum
- Sepsis
- Severe dehydration
- Congestive heart Failure NYHA IV cb Severe Mitral Stenosis
- jaundice DD/ post hepatal
- Apache II score 17

18
OPERATION REPORT (17.15-18.00) : Peritoneal Drainage
Patient lied supine
Antisepsis and asepsis
Infiltration aesthesia with lidocaine 2%
Incised at 0,5 cm caudal from umbilical
Deepened, opened peritoneum
Came out air, yellowish brown fluid, food leftovers (+), faecal (-)
Inserted 3-way Folley catheter 22 Fr into peritoneal cavity,
connected to urine bag initial production 500 cc
connected to infusion set for drainage with NaCL 0,9 %
Fixed with silk 2.0
Closed by steril gauze
Management Post DPL (18.00) :
- Dx :
S:-
O:-
- Tx :
-Drainage Nacl 0,9% 1000 cc ( 30 minutes )
-Pro Exploratory laparotomy
- Mx :
- Complaint, general condition, vital sign, CVP
- Urine output
- DPL production
-IpEx :
- Inform consent :Surgical treatment, Prognosis.
Monitoring (after 30 minutes):
S : pain on abdomen decrease
O: general condition weak, GCS E4M6V5 = 15
Vital sign: :
RR : 22 times per minutes, regular, enough in depth
PR : 92 times per minutes, regular, enough tone
BP : 104/59 mmhg ( MAP = 74 )
T : 36,9 C (A)
pain : 5 VAS
CVP : 7 cmH2O
NGT production 30 cc, brown dark
Statue locate
Abdomen : I : flat, inserted drainage production: fluid serous haemoragic
150cc, food leftovers (-); air
Pa: tenderness on all area, defance muscular (+)
P : not done
A : bowel sound (+)
Working Diagnose (18.05):
Generalized peritonitis cb hollow viscous perforation suspected gaster
DD/ Duodenum
- Sepsis
- Severe dehydration
- Congestive heart Failure NYHA IV cb Severe Mitral Stenosis
- jaundice DD/ post hepatal
- Apache II score 17

Post peritoneal drainage

22
Management Pre Op (18.10) :
- Dx :
S:-
O : rescoring APACHE score
- Tx :
Exploratory laparotomy
- Mx :
- Complaint, general condition, vital sign, CVP
- Urine output
- DPL production
-IpEx :
- Inform consent :Surgical treatment, Prognosis.
0
0
0
0

0
0

2
0
0

0
0
0
5
11
OPERATION REPORT (08.05-10.10) :
Patient lied supine on regional anaesthaesia, desinfected operation area,
narrowed with sterile linen
Midline incision was performed (5 cm caudal from xiphoid process
until 5 cm caudal from umbilicus), deepened until peritoneum
Open peritoneum, came out yellow purulent fluid
Explore the abdomen, found adhesion on ileum teminal, 10 cm from
ileocaecal junction, release adhesion.
Found ruptured diverticule on jejunum, 10 cm from ligamentum treitz,
decided to performed resection of the jejunum 5 cm in length, then
anastomoses end to end with PGA 3-0
Explore the duodenum, jejunum, ileum, caecum, colon ascenden, colon
transversum, colon descenden, colon sigmoid within normal limit
Liver : dull edge, smooth surface
Washed cavum abdominal cavity with warm normal saline as clean as
posible
Inserted 1 intraperitoneal drain with NGT 16 Fr
Close operation wound layer by layer
Operation finished
Post op diagnosed (10.10):
Generalized peritonitis cb diverticule perforation cb ileus
obstruction cb adhesion of ileum terminal
Moderate sepsis
Severe Mitral stenosis
Congestive Heart Failure
Icteric Obstruction DD/Hepatal
APACHE-II score : 11

Post exploratory laparotomy + resection anastomose end to

end of jejunum
Management Post Op (10.15) :
- Dx :
S:-
O:-
- Tx :
- O2 10 lpm
- Inf NaCl 0,9% 20 tpm
- Maintain NGT, Maintan urethral catheter
- Inf. Ciprofloxacin 400 mg/12 hrs intravenous
- Inf Metronidazole 500mg/8 hrs intravenous
- Inj Tramadol 50 mg/8 hrs intravenous
- Inj Ranitidine 50 mg/ 12 hrs intravenous
- Joint management with internal medicine departement
- Mx :
- Complaint, general condition, vital sign, urine output, drain
- Ex :
- Prognosis.
ICU
Follow Up D+1
S : Pain on abdomen decrease
O: general condition look moderate ill, GCS E4M6Vet
Vital sign: :
RR : 21 times per minutes, regular, enough in depth
PR : 89times per minutes, regular, enough tone
BP : 107/62 mmhg ( MAP = 77 )
T : 36,7 C (A)
Pain : 5 VAS
CVP : 7 cmH2O
NGT production 60 cc, yellowish clear
Statue locate
Abdomen : I : flat, inserted drainage production: fluid serous haemoragic
250cc, food leftovers (-); air
Pa: tenderness (-), defance muscular (-)
P : tympnic
A : bowel sound (+) N
A : Stable , Improvement
P: :
- O2 10 lpm
- Inf NaCl 0,9% 20 tpm
- Maintain NGT, Maintan urethral catheter
- Inf. Ciprofloxacin 400 mg/12 hrs intravenous
- Inf Metronidazole 500mg/8 hrs intravenous
- Inj Tramadol 50 mg/8 hrs intravenous
- Inj Ranitidine 50 mg/ 12 hrs intravenous
- Joint management with internal medicine departement
- Mx :
- Complaint, general condition, vital sign, urine output,
drain
-Ex :
- Prognosis.
ICU
CASE REPORT (10.00)
Female, 49 year old, came to emergency instalation, consulted from gynecology
departement with chief complaint pain and dark color on her right leg

Chief complaint : pain and dark color on her right leg

History of Illness :
1 week ago patient complained of pain on his right leg. Pain existed all day and
avoided her from doing his daily activity. Pain relieved with rest .Then her leg
began to swollen,and it gets bigger day by day.
5 days before admission, pain still exist, patient felt the colour of her leg
became dark, because of the pain no decreases with medication, she came to ER
History of trauma (-), nausea (+), vomitus (+). Patient has a history of Ca
cervix in 2014. Patient has undergo surgery and chemoterapi 4x and radiation
49x. Patient also has routine visits to the ginecologyst in RSDK.
History of Past Illness :
History of Cervix Cancer illness (+) 3 year ago
Post chemotherapy and external radiation 6 month ago
Diabetes melitus (-)
Hypertension (-)
History of smoking (-)
Physical examinations:
General conditions: looks moderatelly ill
Vital signs:
RR = 20x/min, regular, and enaught in depth
PR = 104x/min regular, adequate tone and volume
BP = 110/80mmHg
t = 37 0C
Pain scale = 5-6 VAS
GCS = E4M6V5 = 15

Head : injury mark (-)

Eyes : palpebra conjunctiva wasnt pale
round isocoric pupil 3mm, light reflex (+)/(+)
Neck : No injury mark, JVP not increase, trachea in the middle
Thorax: retraction (-), injury mark (-)

Heart:
I : ictus cordis not visible
P : ictus cordis palpated on the 6th
ICS left MCL.
P : heart configuration WNL
A : heart sound clear, no murmur

Lungs:
I : static: left hemithorax = right hemithorax
dynamic : left hemithorax = right hemithorax
P : Tactile fremitus left = right
P : Sonor on all area

A : vesicular on area, additional sound (-)

Abdomen:
I :Injury mark (-), Flat
P :Smooth, no tenderness, no muscle rigidity.
P :Tympanic, liver dullness(+)
A :bowel sound (+) normal.

Pelvic : no injury mark, stable

External genitalia: female WNL
Extremity Sup Inf
Edema -/- local state/+
Capp refill <2/<2 local state/-
Motorik 555/222 local state/555
Sensorik ++/++ local state/++

Local State
Right lower leg :
Look : Dark skin necrotic (+) 1/3 middle right leg - foot, bullae
(+), oedema (+)
Feel : cooler than contralateral, pain (+), pulse of dorsalis pedis
artery (-), pulse posterior tibialis artery (-), pulse
popliteal artery (-), pulse femoral artery (-), Cappilary reffil (-),
sensibility (decrease)
ROM : Active and passive movement limited by pain
Laboratory study (Kariadi Hospital) 12.13:
Hb : 7,6 gr % (13 16 gr%)
Ht : 23,5% (35 47 %)
Lekosit : 27.400/mmk (3,6 11 rb/mmk)
Tromb : 157.000/mmk (150 400 rb/mmk)
PPT/K : 17.1/15.0 (11,1 12,4 det)
APTT/K : 38.2/36.8 (32,3 33,1 det)
GDS : 90 mg/dL (80 140 mg/dL)
Ur : 58 mg/dl (15 39 mg/dl)
Cr : 1,1 mg/dl (0,5 1,5 mg/dl)
Na : 139 mmol/l (136 145 mmol/L)
K : 4.7 mmol/l (3,5 5,1 mmol/L)
Cl : 99 mmol/l (98 107 mmol/L)
Working Diagnose (12:17)
Sepsis
Acute limb ischemia on right lower leg cb arterial occlusive diseases
Adeno ca cervic TxN2M1 liver st.IV
Anemia

Initial management
IP. Diagnose:
S:-
O: -

IP. Therapy:
IVFD RL 20 drops/min
Inj. ketorolac 30mg/8hr intravenous
Transfusion PRC
Embolectomy

IP. Monitoring : general condition, complaint, vital sign

IP. Education : Informed consent : Diagnosis, surgical treatment,
prognosis.
Operation report (15.17-17.00)
Patient laid supine under regional anesthesia
Antiseptic and Aseptic operation area
Performed longitudinal incision in right femoral region, deepened
incision layer by layer, identification of right femoral artery place
vascular fixation at proximal and distal of the artery
Performed tranversal incision in the arterial wall, inserting fogarty
catheter no. 6
The forgaty catheter is inserted 20 cm towards the abdominal aorta. 45
cm down to popliteal bifurcation and 70 cm to ankle. Balloons are
developed 1 cc after transversion of the thrombus and then developed
and extradited.
Out trombus about 5 cc.
Performed evaluation of right dorsalis pedis artery pulsation (+),
normal flow.
Suture the surgical incision of the artery using polyprophylene 6.0
Inserted drain with NGT no. 10
Suture the surgical wound layer by layer.
Operation finished
Post operative Dx 17.05:
Sepsis
Acute limb ischemia on right lower leg cb arterial occlusive diseases
Adeno ca cervic TxN2M1 liver st.IV

post embolectomy

Post operative management (17.10) :

P. Diagnose:
S:-
O: -
P. Teraphy:
- RL Infusion 20 drops/ minute intravenous
- Injection ceftriaxone 2gr/24 jam intravenous
- Injection Ketorolac 30 mg/8 jam Intravenous
- Heparine 3000 IU in 30 minutes, continued with 500 IU over 24 hours

P. Monitoring : general condition, complaint, vital sign, operation wound,PTT/K

( 6 hours )
P. Education
Operation finding, plan treatment
Follow Up D+1
S : Pain on right leg
O: general condition look moderate ill, GCS E4M6V5=15
Vital sign: :
RR : 21 times per minutes, regular, enough in depth
PR : 89times per minutes, regular, enough tone
BP : 110/80 mmhg ( MAP = 90 )
T : 36,6 C (A)
pain : 5 VAS
Local State
Right lower extremity :
Look : post operation wound cover by gauze , imbibition (-), Dark skin
(+) 1/3 middle right leg - foot, bullae (+), no oedema, Drain (+) 20cc/24 hour
serohemoragic
Feel : warm than before operation, contralateral, pain (+), pulse of
dorsalis pedis artery (+) weak,pulse posterior tibialis artery (+) enough, pulse
popliteal artery (+) enough ,femoral artery (+) enough, Cap. Reffil 1-2sec,
sensibility (+)
ROM : Active and passive movement limited by pain

A : Stable , Improvement
P:
-RL Infusion 20 drops/ minute intravenous
-Injection ceftriaxone 2gr/24 jam intravenous
-Injection Ketorolac 30 mg/8 jam Intravenous
-Heparine 4000 IU in 30 minutes, continued with 500 IU over24hours
-joint management with Obsgyn departement

Monitoring : general condition, complaint, vital sign, operation wound,

Education : plan treatmen

GRD 5
Monday, 5th June 2017