Duty Report

Tuesday, 16th July 2019

Consultants on duty
dr. Juni Mitra, SpB(K)BD
dr. Syaiful Saanin, SpBS
dr. Dody Efmansyah, SpB, SpU
dr. Hendra Maska, SpOT

Residents on duty
Yoki, Magdi, Zaki, Nando, Ihsan, Dicky, Andre, Aldo,
Rama, Ridho, Flori
• Total Patients : 7 Patients
 Patients underwent surgery : 1 Patient
 In Patients : 3 Patients
 Out Patient : 3 Patients
 Refused to treatment : - Patient

Ward report :
• CP : 15 Patients
• CW : 21 Patients
• CAA : 5 Patients
• TC : 14 Patients
• BR : 3 Patients
• RR : 7 Patients
Underwent Surgery
 1st Patient

A male patient 16 years old was admitted to

emergency room with

Chief Complaint :
Pain at the right lower abdomen for 1 day before
admision

4
Present Illness History

- Pain at the right lower abdomen for 1 day before

admision
- Pain was begun at the periumbilical site and shifted to
right lower abdomen
- Pain was felt continously and increased by movement
- Fever (+), Anorexia (+), nausea (+), vomits (–)
- Defecation and micturation were normal
 Physical Examination

- General appereance : Moderately illness

- Conciousness : Compos mentis
- Blood pressure : 120/80 mmHg
- Heart rate : 92 x/minute
- Respiratory rate : 22 x/minute
- Temperature : 38,2 °C
- VAS :6

- Eyes : conjunctive was not anemic

- Thorax was normal
 Locally State
Abdominal region :
I : Distended (–)

A: Bowel sound (+)

P: Muscle rigid (+), tenderness (+), rebound tenderness (+) at the

right lower quardrant

DRE

Pain at the anterior site (+)

Working Diagnosis :
Suspected acute appendicitis

Laboratory :
Hb : 13,4 gr%
Leucocyte : 12.800/mm3
Patient was prepared to the preoperative room
- Informed consent
- NPO
- IVFD
- Antibiotic
- Report to anesthesiologist

Planning:
Appendectomy emergency
 Operative Report
• Supine position under spinal anesthesia
• Desinfected the operating field
• Tranverse incision through Mc. Burney point, open
fascia, muscle splitting, open peritoneum
• Luxir caecum, found appendix at the pelvic site:
erectile, oedem, hiperemic, size 7x2 cm
• Performed appendectomy
• Closed operative wound layer by layer
Intra Operative Picture
Diagnosis :
Acute appendicitis

Patient's condition this morning :

Patient is in the ward
S : Fever (-), Defecation (-)
O : BP = 120/ 80 mmHg, RR 18x/i, HR: 84 X/i, T : 37 0C
Abdomen:
I : Distended (-), dreasing is good
A : Bowel sound (+)
A : Post Appendectomy due to acute appendicitis POD 2
P : Discharge today
Inpatient
 1st Patient

A male patient, 15 years old was admitted to emergency room

with

Diagnosis:
Traumatic brain injury GCS 15
Open fracture simphysis mandible
Closed fracture of corpus of mandible

Plan :
Debridement and ORIF
Clinical Picture
Head CT Scan
Head CT Scan
 2nd Patient

A male patient, 16 years old was admitted to emergency room

with

Diagnosis:
Closed Fracture of left angulus and simphysis mandible

Plan :
ORIF elective
Clinical Picture
Head CT scan
Head CT Scan
 3rd Patient

A male patient, 70 years old was admitted to emergency room

with

Diagnosis:
Acute limb Ischemic at left cruris and pedis
DM type 2
Hypoalbuminemia

Plan :
Heparinization
Clinical Picture
 Laboratorium Finding
Hb : 13,7 gr/dl
Leucocyte : 12.380/mm3
Trombocite : 159.000/mm3
Ht : 41%
PT : 11,6 second
APTT : 40,2 second
D-Dimer : 4289 ng/ml
Blood Glucose : 217
Albumin : 2,5