CASUALTY REPORT

Day/ Date: Friday, July 29 th, 2016

Doctors on Duty: Hamida, MD/ Valdi, MD/ Yoni,
MD Dita, MD/Ayi, MD Mona, MD
Consultant on Duty: Mirta Hediyati, MD, ORL
Larynx Pharynx Division Consultant on Duty:
Syahrial M.H, MD, ORL
 CHIEF
COMPLAINT
IDENTITY

Male, 67 years old Difficulty in breathing since 3

months prior to admission.
Getting worse since 2
days.
Medical History
Difficulty in breathing since 4 months prior
to admission. There was noisy breathing,
and it getting worse since 2 days ago.
There was voice disturbance since 2
months ago. Cyanosis (-)
Patients have been treated to Tarakan Hospital
and has done a CT scan of the larynx and said
laryngeal tumors. 4 months ago the patient had
been referred to Hermina Hospital for further
examination, but the patient does not run.
 No History discharge from the ears, hearing
decreased.
Nasal blockage at left nostril since 2
months ago. Double vision (-), facial pain
(-).
Patients can only eat soft food and liquid.
A history of choking after eating there, the sound
disappears from that previously existed..
Physical Examination
Compos mentis Right and left ear: Wide ear
There was dyspnea, canal, no cerumen,
tympanic membrane was
stridor, retraction at intact
supraclavicula, stridor + Right and left nose:
Vital signs: Wide nasal cavity, inferior
Pulse : 88x/min turbinate eutrophy, secrete-,
BP : 130/70 blood-, air passage +/-
RR : 28x/min
Temp : 36 0C
SaO2 : 99 % on
simple mask 5lpm
Physical Examination

Throat and oral cavity :

Pharyngeal arcus was symetry. uvula in the middle,
tonsils T1-T1 calm, quiet posterior pharyngeal
Neck Region
enlarged lymph nodes does not exist
Working Diagnosis
Upper Airway Obstruction grade 2 ec.
Laryngeal mass ( J37.8)
 Management

Observation of vital signs and tightness

O2 NRM 6 lpm
Dexametason 5 mg IV
Ventolin inhalation NaCl 1: 1
Report Syahrial, MD .ORL
-plan for primary tracheostomy
-consult to Internal medicine and anesthesia
-Blood examination and X-rays of the thorax and
cervical AP / lateral
Lab Examination
(July 29th 2016)
Hb 14,4 g/dl
White blood 10800/Ul PT 10,3(10.4)
cells APTT 36,8(35.1)
Platelets 197.000/Ul Ph 7.385
SGOT 23
pCO2 40.8
SGPT 21
pO2 176,2
Ureum 52
Creatinin 0.35
SaO2 99,5
RBG 90 mg/dl BE -0.2
Pottasium 3,8 mEq HCO3 25,9
Sodium 138 mEq
Chlorida 106 mEq
Consultation
(December 10th 2015)
Internal Medicine Department:
Hematology Tolerance : moderate
Cardiology Tolerance : moderate
Pulmonology Tolerance : moderate to severe
Metabolic Tolerance : moderate

Anesthesiology Department:
ASA III with impending obstruction airway ec.
Laryngeal mass
Radiological Findings
(, 2016 before tracheostomy)

Soft tissue tswelling on regio colli

bilateral with tracheal constriction
as high as corpus C5-C7
 Minimal infiltrates
the upper right
lung field
Working Diagnosis
Management
TMRC tried intubation twice, with ETT size 7 and 7.5,
but did not succeed. Evaluation: plika vokalis and
ventricular edema and hyperemia, rima glotis <30%
open
Report to Dr. Fauziah Fardizza, MD ORL (K)
Acc to cito primary tracheostomy
Informed consent
Tracheostomy Surgery Report
CMER (July 5th, 2016)

Intraoperative:
-Cito primary tracheostomy - Release thyroid from trachea
was performed aspiration bubble (+)
- Trachea incision at tracheal
-Extension position ring 1-2 (bjorc flap) Insert
-A/antisepsis in operating traceostomy canule no.8
field evaluation: air passage (+)
-Local anaestetic with - Bleeding control
lidocain 2% in incision Post operative:
region Stoma : air passage (+),
-cutaneous incisionblunt serohemorrhagic secrete, no
dissection active bleeding, no crepitation
Post Operative Instruction

Observation of vital sign, bleeding, and crepitation

Thorax x-ray post operative
Tracheostomy canula care
Tranexamic acid 3x500 mg i.v
Ketorolac 3x30 mg i.v
Antibiotic and other therapies according to internal
medicine department
Consult to internal medicine for joint care
Larynx pharynx ENT division will follow up
Radiological finding July 5th, 2016
(post tracheostomy)
There was fibrioinfiltrat in the
upper-middle area of both
lungs, lung DD/TB,
pneumonia
Bilateral apical pleural
thickening
Distal tracheostomy canule
were placed 1 corpus above
carina
There was no pneumothorax,
pneumomediastinum, nor
subcutaneus emphysema
Larynx-Pharynx Division
(July 5th, 2016)
S : inadequate patient contact A :
O : Compos mentis, Dyspneu Grade III upper airway obstruction
(-), Retraction (-), Stridor (-) suspect laryngitis tuberculosis
post tracheostomy H-0
BP : 126/85 HR : 120x/min
Suspect lung TBC with syndrome
RR : 30 x/min T : afebrile of post-TBC obstruction
sat.O2 85% on bagging P:
10 l/min Vital signs observation,
Right nose: nasogastric tube general conditions, and
bleeding
(+)
Other therapies according to
Stoma : air passage (+), kardex
serohemoragic secretion, Thorax x-ray post o.p
crepitation (-) AP/lateral
Internal Medicine Department
(July 5th, 2016)
S : adequate patient contact, short
breathing
O: General condition: seems acutely upper airway in tracheostomy
ill
consciousness: apatis, somnolen
BP : 120/80 HR : 130x/min
RR : 28 x/min T : 36.7 C
sat.O2 85-90%
Head: Normocephali, no sclera icteric
Neck: jugular vein pressure 5-2 cmH2O
Thorax: Heart: Heart I and II sounds
regular, no murmur and gallop
Lungs: vesicular breath
shortness
Abdomen: stomach rumble (+)
Extremitas: edema (-)
A:
1.Type-2 respiratory failure EC destructed
2.Upper airway obstruction EC edema
larynx , suspect laryngitis TBC DD/ massa
3.Sepsis EC community acquired
pneumonia
4.Community acquired pneumonia DD/
lung TBC relapse with secondary infection
5.Dyspepsia
P:
Therapy: according medical instruction by
kadex
Larynx-Pharynx Division
(July 6th, 2016)
S : complaint of canule
dislocation feeling, shortness
of breath (-)
O : Compos mentis, Dyspneu
(-), Retraction (-), Stridor (-)
BP : 105/68 HR : 113x/min
RR : 24 x/min T : afebrile
sat.O2 97% on bagging
10 l/min
Right nose: nasogastric tube (+)
Stoma : air passage (+),
serohemoragic secretion,
crepitation (-)
A:
Grade III upper airway obstruction
suspect laryngitis tuberculosis
post tracheostomy H-1
Suspect lung TBC with syndrome
of post-TBC obstruction
P:
care and periodic suction
Evaluation: air passage (+),
sat.O2 = 98%
Bagging disengagement trial
for 2 seconds air passage
(+), sat O2= 88% advise:
postpone trachvent activation
Larynx-Pharynx Division
(July 8th, 2016)
S : shortness of breath (-),
cough (+)
O : Compos mentis, Dyspneu
(-), Retraction (-), Stridor (-)
BP : 117/70 HR : 92x/min
RR : 20 x/min T : afebrile
sat.O2 97% on trach vent
Right nose: nasogastric tube (+)
Stoma : air passage (+),
seromucoid secretion, bleeding
(-), clotting (-), crepitation (-) Other therapies according to
A:
Grade III upper airway obstruction
suspect laryngitis tuberculosis
post tracheostomy H-3
Suspect lung TBC with syndrome
of post-TBC obstruction
P:
Vital signs and shortness of
breath observation
Canule treatment education to
the family
kardex
Larynx-Pharynx Division
(July 9th, 2016)

Report to Dr. Fauziah Fardizza, MD ORL (K):

ENT department states no further problem: sat.O2 97%
on trach vent
Acc the patient was discharged from ENT department.
Canule treatment education to the family
Thank
You