Duty report

Sunday, 1st March 2015

19.00-05.00

Consulent : dr. Toni SpB

Resident : dr. Adrian, dr. Rifki, dr. Budi
Coass : Ratu, Nilam, Putra, Icha, Yitta, Anas

 Stagnant patient : 5 patient

New patient : 3 patient
Operation : 2 patient

Stagnant patient
1. Mrs. Ratih/ 74 yo/ 486380/ abcess ulcus
diabetic right leg/ incision
2. Mr. Wirasto/54 yo/ 1352350/ selulitis pedis
dextra, CHF, AKI/ wound dressing
3. Mr. Ishak Ahmad/ 17 yo/ 1352371/ acute
appendicitis/ appendictomy cito
4. Mr. Mintra/ 62 yo/ 1352392/ right hernia
scrotalis irreponible/ herniotomy cito
5. Sahila/ 2 yo/ 1352398/ combustio grade II A
TBSA 15%/ wound dressing

New patient
1. Mr. H. Mamat/ 59 yo/313210/ multiple
complete fracture os costae 5,6,7
posterior dextra/ conservative, home care
2. Mr. Djuhari Mamat/ 55 yo/1352414/
Vulnus laceratum pedis dextra/ WT,
hecting
3. Mr. Nasrullah/34 yo/1248890/ suspect
Acute Appendicitis, DHF/ Conservative,
consultation to internist for DHF
treatment

Mr. Djuhari Mamat/ 55 yo/1352414/

Vulnus laceratum pedis dextra

OPERATION

Case Illustration
IDENTITY
Name
: IA
Age
: 17 yo
Sex
: Male
Occupation
: Student

Anamnesis
Auto anamnesis was done on 1st of March, 2015

Chief Complaint

Lower right abdominal pain since 2

days before hospital admission

History of present illness

Patient complaints of acute abdominal pain which started from 2 days
before hospital admission. The pain felt continously until he feel to
twining. Nausea (-), vomitting (-), abdomen bloating (+), fever (-),
diarrhea (+) from 2 days ago, frequency 2-3 times every day. Urinate
normal.

Past medical history

Surgical history (-)

Allergy (-)
Asthma (-)

Family medical history

Allergy (-)
Asthma (-)

Physical Examination

General state
: Moderate sickness
Awareness : Compos mentis
Vital sign :
Temperature: 37C
Pulse: 106x/min
Respiration: 20x/min
Blood Pressure: 126/74

Head : normocephal, no deformity

Eyes : conjungtiva pale -/-, icteric sclera -/Lungs : normal breathing sound, rhonki -/-, wheezing -/Heart : heart sound is normal, murmur (-), gallop (-)
Abdomen : tenderness in the right iliac fossa, local guarding
and rebound tenderness at the McBurney point, muscular
defense (-), psoas sign (-), rosving sign (-), obturator sign (+)
Extremitas
: edema on joints or ankles are absent
DRE
: tone of the anal sphincter good, prostate non
palpable, tenderness (-), stool (-), mucous (-), blood (-)

Preoperative

Laboratory (1/3/2015)
Test
Hb
Haematocyrit
Leucocyte
Trombosit
GDS

Result

Normal value

15 gr/dl

11,7- 15,5

46 %

33-45

18.000

5000- 10000

371.000 ribu

150 ribu- 440 ribu

96 mg/dl

70-140

Natrium

138 mmol/l

135-147

Potassium

4,76 mmol/l

3,1-5,1

Chloride

103 mmol/l

95-108

Diff count

0/1/81/13/4

PT/APTT
Urinalysis

14,3/40,1
Albumin (Trace)
Blood/Hb (Trace)

11,3-14,7/ 27,4-39,3

Chest
Rontgen

Normal heart
Lungs :
infiltrates in left
and right lungs,
especially in
both apex.
Sugestive TBC

Working Diagnosis
Acute Appendicitis

Treatment

Appendectomy cito
Consultation to Pediatric
Antibiotic Ceftriaxone
Metronidazole 3x500 mg
Fasting

2x1

gr,

Operation Report
1.Patient lay in spinal anesthesia on operation table in supine
position.
2.Aseptic and antisepsis procedure was done at the operation field
and the surrounding area
3.Oblique incision perpendicular to McBurneys into cutaneous,
subcutaneous, fascia, muscle separated by blunt
4.When the peritoneum was opened, nothing came out from it
5.Identification of the cecum, appendix located retrocecal
intraperitoneal, hyperemia (+), fecalith (-), perforation (-),
appendix size 5x1x1 cm
6.Appendectomy was done, appendix stump embedded in the
cecum with tobacco sacc suture
7.The abdominal cavity was being cleansed using a sterilized
saline
8.Control bleeding
9.The surgical wound were sutured layer by layer
10.
Operation finished

Intra operative

Post operative

Post-operation Instruction

Observe vital signs

Normal diet when fully awake
IVFD RL : D5 = 2 : 1 / 24 hours
Ceftriaxone 2x1 gr i.v
Ketorolac 3x30 mg i.v
Ranitidine 2x50 mg i.v

Hernia scrotalis

PATIENTs IDENTITY
Name : Mr. Mintra
Age : 62 yo
MR
: 1352392
Anamnesis was done on 1st march
2015

History of Present illness

Chief complaint :
Theres a lump in the right scrotum that have
been 5 years. The lump appears all of sudden when
patient doing an activity and vanish by it self by
rest, there was no pain when the lump appears
back then. But now, the lump dont want to back by
it self by rest and by patient force, and feeling of
heaviness and aching. The other complaint, theres
an abdominal pain. Nausea and vomiting are
present. Also feeling heavy when inhale. Defecation
normal in the morning, mixtion spontan, clear.

Past medical history

Surgical history (-)

Allergy (-)
Asthma (-)

Family medical history

Allergy (-)
Asthma (-)

Physical Examination

General state
: Moderate sickness
Awareness : Compos mentis
Vital sign :
Temperature: 37C
Pulse: 92x/min
Respiration: 20x/min
Blood Pressure: 90/70

Head : normocephal, no deformity

Eyes : conjungtiva pale -/-, icteric sclera -/Lungs : normal breathing sound, rhonki -/-, wheezing -/Heart : heart sound is normal, murmur (-), gallop (-)
Abdomen : flat, bowel sound (+) normal, palpable pain (-),
hepar lien non palpable
Extremitas
: edema on joints or ankles are absent
DRE
: tone of the anal sphincter good, prostate non
palpable, tenderness (-), stool (-), mucous (-), blood (-)

Physic exam (local)

Right scrotum: mass (+),
undetermine marginated,
erithema (-), tenderness
(-)

Standart value Result

Darah rutin

Hemoglobin

13,2-17,3

15 g/dL

Hematokrit

33-45

44 %

Leukosit

5.000-10.000

11800/uL

Trombosit

150.000440.000

267.000/uL

Fungsi Ginjal

Ureum darah

20-40

34 mg/dL

Creatinin darah

0,6-1,5

0.9 mg/dl

Diabetes

Gula darah Puasa

80-100

95 g/dL

Standart value Result

Fungsi Hati

SGOT
SGPT

0-34

19 mg/dL

0-40

19 mg/dl

Elektrolit

Na

135 147

133

3.1-5.1

4.8

Cl

95-108

103

Hemostasis

APTT / control
PT / control
INR

28.8/31.5 =
0.89
12.1/13.5 =
0.89
0.87

Chest
Rontgen

Sight
cardiomegali
Lungs :
infiltrates in
basal right
lungs. Sugestive
Pneumonia

Diagnosis
Hernia scrotalis dextra irreponible

Treatment

Pro herniotomy cito

Ceftriaxon 1x2 gr
Ketorolac 3 x 30mg
Omeperazole 2 x 40 mg

OPERATION REPORT
Herniotomy + Hernioplasty with MESH
Patient was on supine position under spinal anesthesia
A and antiseptic prosedure was done on operation field
Incision was done started from 2 fingers above SIAS to
tuberculum pubicum across cutis, subcutis, and fascia until
funniculus spermaticus exactly found
Identification of hernial sac, a serous fluid was found about
10 ml. Hernial sac contained vital omentum
Omentum was inserted back to abdominal cavity
Proximal and distal part of hernial sac was separated
Proximal part of hernial sac was sutured by purse string
suture on peritoneal fat level
MESH was patched, sutured on tuberculum pubicum,
ligamentum inguinale, and cojoint area
Operation wound was cleaned and sutured layer by layer
Operation completed

Post operation instruction

Observe vital sign
Ivfd: RL:D5 2:2/24 hours
Regular diet after patients fully
concious
Ceftriaxone 2x1 gr
Ketorolac 3x30 mg
Omeprazole 2x40 mg

THANK YOU