Tuesday, 7th May 2019

REN/BRO/SEL/PUT/TOM/WHS/RAF/RDP/RHS/YDA/ SNU/VLE
In Emergency installation we received … patients, consist of :

No Diagnosis Plans
1. Laceration wound (T14.1) Debridement
Suturing
Amoxycillin 500 mg/ 8 hours orally
Mefenamic acid 500 mg/ 8 hours orally

 2 Patient  Discharged

2. Avulsion fracture of teeth 1.1 and Wound toilet

1.2 (K.03.1) Paracetamol 500 mg / 8 hour orraly
Excoriation wound face region Panoramik X-ray
(T14.0) cb fall 30 minutes
before admission

 1 Patient  IGD
3 3rd Grade ulkus decubitus of sacrum
region (L89.90) cb imobilization cb
geriatry syndrome
Anemia (D64.9) cb hematoschezia
(K.92.1)
 1 Patient
4. Severe head injury (S.06.0) GCS
E2M3V2 = 7
Diffuse Axonal Injury grade III (S.06.2)
Uncomplicated closed fracture of left
metatarsal I-IV transverse displaced
(S92.3)
Uncomplicated closed fracture of
proximal phalang of left thumb
foot(S92.2) cb traffic accident 18 hours
before admission
 1 Patient
Oxygenation
Wound dressing with moist and dry gauze
Ampicilin sulbactam 1,5 g / 8 hour intravenous
PRC transfusion
Elective colonoscopi
 IGD
Oxygenation
Head up 300
Observation
Maintain cervical collar
Urethral catheter application
Spalk application
Ketorolac 30 mg / 8 hour intravenous
Ranitidin 50 mg / 12 hour intravenous
Phenytoin 200 mg / 24 jam
Mannitol 125 cc loading dose, maintenance 65
cc / 6 hours intravenous
 IGD
5. Soft tissue contusio dextra ankle Wound toilet
regio (S20.219) Hecting
Laseration wound pedis dextra Amoxicilin 500 mg / 8 hour oraly
regio(T14.1)
Asam mefenamat 500 mg / 8 hour oraly
Laseration wound pedis dextra
digiti II region(T14.1)

 IGD
 1 Patient

6. Soft tissue contusion of chest Mefenamic acid 500 mg / 8 jam orally

(S20.211)

 1 Patient  Discharged

7 Soft tissue contusion of right foot Elastic bandage application

(S20.214) Mefenamic acid 500 mg / 8 jam orally
cb slipped 15 minutes before
admission
No Diagnosis Plan
8. Cervical canal stenosis cb Ketorolac 30 mg/ 12 hour intravenous
multiple HNP C2-3,C3-4, Elective cervical laminoplasti
C4-5 (M.48.2)

 1 Patient
 Parkit

9. Septic arthritis genue sinistra Ketorolac 30 mg / 8 hour intravenous

(M00.869) Ampicillin sulbactam 1.5 gr / 8 hour
intravenous
Elective left Total Knee Replacement

 1 Patient  R6A
No Diagnosis Plan
10. Suspect closed fracture of 5th Wound toilet
finger of right foot (S26.60) Suturing
Laceration wound of right foot Neighboring spalk application
(T14.1) Right foot x-ray AP/Oblique
Elective ORIF

 1 Patient  Gerd D

11 Charcoat joint pedis sintra Keterolac 30 mg/ 8 hour intravenous

DM type II (M14.671) Arthrodesis elective
Join management with internist
department

 1 Patient  IGD
No Diagnosis Plan
12 CKD stage V (N18.9) Double lumen application
DM type II (E11.8)

 1 Patient  IGD

13 Adecuate MAR with Keep warming

rectovestibular (Q42.3) X foto baby gram
Colostomy elective

 1 Patient  IGD

14 Adeno Ca Paru (C34.90) KT 6x Oksigenasi

(zometa) Head up 30
Hemispere sinistra c/ SNH MSCT craniocerebral without contras
Raber with TS Neurologi

 1 Patient  IGD
No Diagnosis Plan
15 Suspect appendicitis (K35.80) Urinalisis
USG Abdomen

 1 Patient  IGD

16 MAR with adequat Keep warm

rectovestibular fistule Baby gram x-ray
(Q42.32) Elective colostomy

 1 Patient  NICU
No Diagnosis Plan
Stoma prolaps ppost ileustomy Stoma care
(12/04/19) cb refistule
enterocutan post fistelectomy
(30/03/19)

 1 Patient  CILD
Adeno Ca Paru KT 6x (zometa) Oksigenasi
Hemispere sinistra c/ SNH Head up 30
MSCT craniocerebral without contras
Raber with TS Neurologi

 1 Patient  GRD I lantai 2

Left breast tumor, Malignant Wound toilet
phylloides tumor of right MST 10 mg / 12
breast post MRM (Feb 2018) Chest x-ray AP
post KT 6x post ER 36x

 1 Patient  IGD
No Diagnosis Plan
Recurrent hematuria cb suspect Oxygenation
malignancy post sistoscopy Maintain 3way urethral catheter
(7/05/19) PRC tranfussion
Anemia

 1 Patient  GRD 2 lantai 5

Retensio urine suspect prostat Maitain urethral catheter

hyperplasia

 1 patient  Discharge
 Tuesday, 7th May 2019
REN/BRO/SEL/PUT/TOM/WHS/RAF/RDP/RHS/YDA/ SNU/VLE
CASE REPORT (04.35)
A 30 year old man came with a chief complain pain on right lower
quadrant of abdomen

Chief compaint : Pain on right lower abdomen

History of Current Illness:

2 days before admission, patient felt pain on his epigastrium, the
pain felt continous, worsening with cough and walking. Fever (+),
naussea (+), vomitus (+), patient felt loss appetite. 1 day before
admission, pain became worsened and migrate to right lower
abdomen,BAK(+),BAB(-) 7 hours before admission then her family
brought her to Kariadi Hospital.

History of Past Illness : pain on urination (-), stone passing (-) blood in
urine (-)
Physical Examination
General Condition: moderately ill
Vital sign :
RR : 20 x / min (regular, adequte depth of breath, no retraction)
PR : 80 x / min (regular, adequate tone and volume)
BP : 120/80 mmHg
Temp: 37,8 ºC (Axillary)
Pain scale : 3-4 VAS
Head/neck : Pale conjunctiva (- / -)
Sclera was not icteric
Chest :
Heart : I : ic was not visible
P : ic was palpable at 5th ics, 2 cm medial from MCL
P : heart configuration within normal limits
A: S1 – S2 within normal limits, no murmur or gallop
rhythm
Lung : I : symetric right and left hemithorax on static and dynamic
P : tactile fremitus was equal on both side
P : sonor on all area
A : basic sound was vesicular, no additional sound
Abdomen :
I : flat, bowel pattern/movement (-)
P : tenderness on the right lower abdomen,
muscle rigidity (-), rebound tenderness (+) Pain on Mc
Burney point (+),Psoas sign (+),Roving sign (+)
P : timpanic, Liver Dullness (+) N, Shifting Dullness (-)
A: bowel sound (+) normal
D.R.E :
adequate anal sphincter tone, smooth mucous, no mass/tumor, ampula
recti was not colaps, tenderness (-)
Glove : stool (+), mucous (-), blood (-)
Genitalia : male, within normal limits

Extremity :
• Ekstremity : Supor Infor
• Sianosis -/- -/-
• Cold acral -/- -/-
• Capp. Refill <2”/<2” <2”/<2”
Working Diagnosis (23.18)
Acute abdominal pain
Suspect acute appendicitis
Management : (23.19)
IPDx :
S: -
O : Abdominal USG

IPTx :
• Ringer lactate 20 drops per minute intravenous

IPMx :
– General condition, vital signs, hematology, differential
count, urinalysis

IPEx :
- Diagnosis, treatment plan, prognosis & informed consent
Lab. Study (RSDK, 14-01-19)
Hb : 14,4gr% (12-15,00)
Ht : 42,1 % (35-47)
L : 7.200 /mmk (3.600 11.000)
Tr : 327.000/mm (150.000-400.000)
Diff count
Eosinofil : 1 % (1-3)
Basofil : 0 % (0-2)
Batang : 2 % (2-5)
Segmen : 61 % (47-80)
Limfosit : 26 % (20-40)
Monosit: 7% (2 – 10_
GDS : 120 mg/dl (80-140)
Na : 135 mmol/l (136-145)
K : 3,7 mmol/l (3,5-5,1)
Cl : 98 mmol/l (98-107)
Ur : 19 mg/dL (15-39)
Cr : 1,0 mg/dL (0,5-1,5)
PPT : 15,0 (10,8 “)
APTT : 35,4“ (30,7 “)

Abdominal USG (RSDK, 08-05-19)

 Alvarado score

Pain on appendicitis point 2

Leucocytosis 0
Vomiting 1
Anorexia 1
Rebound tenderness 1
Abdominal migrate pain 1
Degree of Celcius (> 37.5 C) 1
Raised neutrofil 0
TOTAL 7
 9 - 10 : very probable
 7–8 : Probable
 5-6 : Possible
Diagnosis (23.18)
Acute appendicitis (ALVARADO 7)

Management : (01.35)
IPDx :
S: -
O:-
IPTx :
• Simple Appendectomy
• Cefazolin 1 gr intravena  30 minutes before admission
IPMx :
– General condition, vital signs
IPEx :
- Diagnosis, treatment plan, prognosis & informed consent
Operation report (09.00-10.00)
• Patient supine under general anasthesia.
• Antiseptic and aseptic operation area
• Performed Rockey Davis incision (+ 5 cm) deepened layer by layer from skin,
subcutaneous tissue, fascia Scarpa, aponeurosis OAE, OAI muscle, M.
Transversalis abdominis, fascia transversalis, until peritoneal cavity.
• Identified the appendix: antecaecal, hyperemic, edematous, diameter ± 0,5 cm,
length 8 cm, perforated (-), pus (-), fecalith (+) at appendiceal base
• Performed appendectomy:
– Hold the tip of the appendix with babcock clamp, grasp 2 site of
mesoappendix, cut and ligated mesoappendix.
– Identification base of appendix,clamp 0,5 cm from base of appendix, suture
with the silk 3.0 at the base of appendiks, cut the appendix using mesh
betwen clamps and ligated.  sent to PA departement
• Wash operation area with warm NaCl
• Suture operation wound layer by layer
• Operation finished
Post-operative diagnosis (10.10) :
Acute appendicitis
 Post appendectomy
Management: (09.20)
IPDx :
S: -
O:-
IPTx :
• Ringer lactate 20 drops per minute intravenous
• Ampicilin sulbactam 1,5 gr / 8 hours intravena
• Ketorolac 30 mg / 8 hours intravenous
• Diet: clear water
IPMx :
– General condition, vital signs, sign acute abdomen
IPEx :
- Operative findings, treatment given, prognosis
 Post-operative Day 1
S :-
O:
General condition : Good
RR : 19 times/min (regular, adequate depth of breath)
PR : 80 beats/min (regular, adequate tone and volume)
BP : 110/70 mmHg
GCS : E4M6V5 = 15
T : 37 C
Localy State :
Ins : wound closed by gauze, imbibition (-), edema (-)

A : Stable improvement

P :
– Ringer lactate 20 drops per minute intravenous
 Tuesday, 7th May 2019
REN/BRO/SEL/PUT/TOM/WHS/RAF/RDP/RHS/YDA/ SNU/VLE