Morning Report

Wednesday May 6nd,

2015
Team on duty
dr. Hendra Kastiaji
dr. Rynaldi Andriansya

RSUDZA

( Jaga I )
(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)

Distribution of surgery
No
/961912 patient
1
2
3
4
5
6

Emergency room patient

Hospitalize
Out of clinic
Refuse medical advice
Passed away
Hospitalize room

Room

Patients
Patients
Patients
-

Jeumpa
Jeumpa
Jeumpa
Jeumpa
ICU
HCU
PICU
NICU

1
2
3
4

28/28
28/28
28/28
28/28
7
1
2
5

bed
bed
bed
bed

Patients
Patients
Patients
Patients

ICU ADULT

1.
2.
3.
4.
5.

M Yunus/M/60 yo/Post Craniectomy ec ICH + SDH/ POD 8

Hadijah/ F/52 yo/ snake bite + Abdominal hypertension/ POD 11
Sunardi/M/32 yo/ Post Open Reduction Cervical 5-6 Frankle A/POD 6
Laili/F/42 yo/post craniektomi evacuation ICH + SDH/POD 4
Yusmaniah/F/37 yo/Post op Craniotomy Removal tumor + Vp shunt
ec. Hidrocephalus non communican /POD 1
6. Timakah Shaleh/F/70 yo/Post op Craniotomy Evakuasi EDH/POD 4
7. 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 10

2. Khanza/M/5 days/Post VP Sunt ec Hidrocephalus /POD 8
3. Siti Fatimah/F/4 days/Post VP Shunt ec Hidrocephalus +
meningocele/POD 7
4. Rosmawatis Baby/M/6 Days/Suspect oesofageal Atresia Post
Gastrostomy/ POD 3
5. 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

5
2. Ismail/M/53 yo/Dx. Pos op Total Tyroidectomyec. Tyroid Ca Intra
Thoracal / POD 1

PICU

1. Marlindas Baby/M/2 Mo/dx. Post Op Repair Shunt ar. Peritonial + Post

Vp Shunt ec Hydrochepalus+Bronkhopneumonia+Diare Akut/POD 13
3
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 Response
Date/h
our
patien
t
came
to ER

Examin
ation
hour

Mei 6st
2015

06.50 PM

06.00 PM

Laboratory
Examinatio
n

Radiology
Examinati
on

Send

Res
ult

Sen
d

Res
ult

07.00
wPm

08.00
PM

07.15
PM

08.15
PM

Hour of
Diagno
stics

Date/h
our
patien
t out
from
ER

08.30
PM

11.00
PM

inapropri
ate

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 cmRight
(+), deformity
SpO2 (+)
internal rotation,
foot
haematom (+), bone exposeFinger
(+)
I
100 %
F : Pain (+), NVD (-)
II
98 %
M : ROM limited
III

98 %

IV

97 %

99 %

Secondary survey
Head & Neck
: in Normal limit
Thorax
: in normal limit
Abdomen
: in normal limit
Genitalia
: in normal limit
Upper extremity
: in normal limit
Lower extremity :
At regio right ankle :
L : Lacerated wound 11x 4 x 1 cm (+), deformity (+)interna
rotation,
Right
SpO2
haematom (+), bone expose
(+)foot
Finger
F : Pain (+), NVD (-)
I
100 %
M : ROM limited
II

98 %

III

98 %

IV

97 %

99 %

 VAS : 5

Assessment
1.Dislocation at the right ankle joint
2.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
White Blood Count
Platelets
Hematocrit
CT/BT

: 11,6 gr/dl
: 14.600 /ul
: 217.000/ul
: 33 %
: 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 joint
2. 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 Up
Date
8/5/15
POD II

Pain Blood pressure 120/80 mmhg

(+)
Pulse 86 beats/minute
RR 20 breaths/minute

Dislocation at
the right
ankle joint
(ICD-10-CM
S/L at the right leg region
M25.279)
L : sweeling (+), capilary reffil
Open fracture of
(+).
the cuboid
F : pain (+)NVD (-)
of the right
M: ROM limited
tarsal (ICD10-CM
M25.279)

P
IVFD RL 20
drips/min
Inj Cefazoline
1 gr/12 hrs
Inj.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 Response
Date/h
our
patien
t
came
to ER

Examin
ation
hour

Mei 06st
2015

12.00 AM

11.46 AM

Laboratory
Examinatio
n

Radiology
Examinati
on

Send

Res
ult

Sen
d

Res
ult

12.45
PM

14.00
PM

13.30
PM

14.30
PM

Hour of
Diagno
stics

Date/h
our
patien
t out
from
ER

01.00 PM

09.00 PM

Non
apropriat
e

Chief complain
Pain and difficulty to move at the left hand
Patient illnes history
Patient 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 wristSoft
joint
Hard Sign
Sign
Pulsatile bleeding (+)

Significant hemorrage history (+)

Expanding Hematom (+)

Diminished pulse contra lateral (+

+/-)

Distal ischemic (+)

Neurology abnormality (-)

Bruit (-)

Fracture (-)

SPo2 :

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 hand
2.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
gr/dl
White blood count
Platelet
212.000 /ul
Ht
CT / BT

: 12,5
: 18.400 /ul
:
: 42 %
: 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 (ICD10-CM M66.10)

Follow up
Date
08-0515
POD II

S
Pain (+)

O
Vital sign
BP : 120/80
mmHg
Pulse : 84
beats/mnt
RR : 20
breaths/mnt
S/L at the left
hand :
L:
F:
M:
Spo2 :

Digiti
1

Digiti
2

Digiti
3

Digiti
4

95%

90%

94%

92%

A
Rupture A. Radialis
and a. Ulnaris
of the left
hand (ICD-10CM S53.20)
(ICD-10-CM
S53.3)
Rupture tendon
flexor
digitorum
superficial
,flexor digiti
profunda,
flexor carpi
radialis at the
left hand (ICD10-CM
M66.31)
Digiti
Rupture n.
5
Medianus at
95%
the left hand
(ICD-10-CM

P
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

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 Response
Date/h
our
patien
t
came
to ER

Examin
ation
hour

Mei 6st
2015

08.15 AM

08.10 AM

Laboratory
Examinatio
n

Radiology
Examinati
on

Send

Res
ult

Sen
d

Res
ult

08.20
AM

09.30
AM

9.45

9..55

Hour of
Diagno
stics

Date/h
our
patien
t out
from
ER

09.00 AM

9.45

apropiriat
e

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 (+),
Hard Sign
Soft Sign
F : Pain (+), pulse (+) carotis artery Performed control bleeding
Pulsatile
bleeding (+)
Significant hemorrage history
with
(+)
gauze.
Expanding Hematom (-)

Diminished pulse contra lateral

Distal ischemic (-)

Neurology abnormality (+)

Zone neck

L/S at the left auricula

L : Lacerated wound (+) , 4 x 3 x 1 cm
, hematom (+), partial rupture of a.temporal
superficialis
F : Pain (+)
Abdomen

:
I : distensi (+) minimal,

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

Secondary survey
Head & 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 superficialis
F : Pain (+)
Thorax : in normal limit
Abdomen
:
I : distensi (+) minimal, hematom (-)
A : Bowel sound (+), pain (+)
P : Soepel (+)
P : Tympani (+), liver dullness (+)
Genitalia
: in normal limit
Upper extremity
: in normal limit
Lower extremity
: in normal limit

Assessment
1.Hipovolemic shock grade 3 with
transient response due to rupture
artery of the left neck
2.Blunt abdominal injury
3.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 neck
2.Blunt abdominal injury
3.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 DPL
Consult 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 division
DPL (-), there was no blood and enteric
contain.
Plastic division
Reconstruction auricula

Post Operative Diagnose

1. 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)

Date
8/5/15
POD 2

S
On
ventil
ator
SIM
V 02
35%

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

A
Hipovolemic shock
grade 3 with
transient
response due to
rupture of the
left a.facialis, of
the left
a.transversalis
S/L at the right leg region
and of the left
L : Performed anterior
superficial
slab
temporal artery
wound operation dry
(ICD-10-CM
F : NVD (-)
R57.1) (ICD-10M: ROM limited
CM I72.8)
Rupture solid organ
(ICD-10-CM
C83.39)
Lacerated wound at
the left auricula
(ICD-10-CM
S01.00)

Follow Up

P
IVFD RL 20
drips/min
Inj Cefazoline
1 gr/ 12 hour
Inj.Ketorolac
30 mg/ 8
hour
Terapi ICU
fentanyl
30mg
profpofol
100mg
norepinefrin
0,2mg

Patient identity
Name : Ilham Saputra
Age
: 14 year old
Sex
: Boy
Address
: Blangtuphat timur,
lhokseumawe
Fathers phone : 082367376827
MR : 1050943
Admission time : 04 50 AM

Time respond
Date/Ti
me
patient
came to
ER

Examinati
on hour

5/05/201
5
04.50
AM

05.00

Laboratory
Examination

Radiology
Examination
Resul
t

Time
of
Diagno
stics

Date/Ti
me
patient
out
from ER

Send

Resul
t

Send

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 Examination
Primary 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 region
L : 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 result
Head 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-10CM 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 Diagnosed
1.Moderate Head Injury (ICD-10CM 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
8-052015
POD
II

(-) Pulse: 86
Moderate Head
Injury (ICD-10beats/minute
CM S09.8)
RR: 20 breaths/
minute
Fracture
GCS: (E2 M5
depressed at
V3) ; isochoric
the right
pupil 3
parietal
mm/3mm, no
region (ICD 10
CM SO2)
lateralization,
light reflex (+/+) EDH at the right
parietal
region (ICD
10 CM S06.4)

P
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/Ti Exam Laboratory Radiology Time
me
inati Examinatio Examinatio
of
patient
on
n
n
Diag
came to hour Send Resu Sen Resu nosti
ER
cs
lt
d
lt

Date/
Time
patie
nt
out
from
ER

5/0/2015 02.00 02.15 03.30

01.50 AM

10.20 Inappr
PM
opiate

03.1
5

04.0
0

02.00

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 examination
Primary survey :
A
: Clear
B
: Spontaneous, RR: 20 breaths/
minute,
C
: Pulse 85 beats/minute, Blood
Pressure: 140/80 mmHg
D
: GCS : E3M6V5 : 14; isochoric
pupil, 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 result
Head 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 injury
2.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 up
Date
8-52015
POD I

Pain GCS : E3 M6V5

(+) Isochoric pupil
3mm/3mm
BP :130/90 mmHg
HR : 80 beats / mnt
RR : 20
breaths/mnt
Sl. Right Parietal
L : gauze dry
F : Pain (-)

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

P
Head up 30
0

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