night report 1 march_new
TRANSCRIPT
Duty reportSunday, 1st March 2015
19.00-05.00
Consulent : dr. Toni SpB
Resident : dr. Adrian, dr. Rifki, dr. BudiCoass : 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 IllustrationIDENTITY• Name : IA• Age : 17 yo• Sex : Male• Occupation : Student
AnamnesisAuto anamnesis was done on 1st of March, 2015
Chief Complaint
Lower right abdominal pain since 2 days before hospital admission
History of present illnessPatient 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
Family medical history
Surgical history (-)Allergy (-)Asthma (-)
Allergy (-)Asthma (-)
Physical Examination• General state : Moderate sickness• Awareness : Compos mentis• Vital sign :
– Temperature: 37°C– 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 Result Normal value
Hb 15 gr/dl 11,7- 15,5
Haematocyrit 46 % 33-45
Leucocyte 18.000 5000- 10000
Trombosit 371.000 ribu 150 ribu- 440 ribu
GDS 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 14,3/40,1 11,3-14,7/ 27,4-39,3
Urinalysis Albumin (Trace)Blood/Hb (Trace)
Chest Rontgen
• Normal heart• Lungs : infiltrates
in left and right lungs, especially in both apex. Sugestive TBC
Treatment
Working Diagnosis
Acute Appendicitis
• Appendectomy cito• Consultation to Pediatric• Antibiotic Ceftriaxone 2x1 gr, Metronidazole
3x500 mg• Fasting
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 area3. Oblique incision perpendicular to McBurney’s into cutaneous,
subcutaneous, fascia, muscle separated by blunt4. When the peritoneum was opened, nothing came out from it5. 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 saline8. Control bleeding9. The surgical wound were sutured layer by layer10. 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
PATIENT’s IDENTITY
• Name : Mr. Mintra• Age : 62 yo• MR : 1352392
Anamnesis was done on 1st march 2015
History of Present illness
• Chief complaint : There’s 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 don’t want to back by it self by rest and by patient force, and feeling of heaviness and aching. The other complaint, there’s an abdominal pain. Nausea and vomiting are present. Also feeling heavy when inhale. Defecation normal in the morning, mixtion spontan, clear.
Past medical history
Family medical history
Surgical history (-)Allergy (-)Asthma (-)
Allergy (-)Asthma (-)
Physical Examination• General state : Moderate sickness• Awareness : Compos mentis• Vital sign :
– Temperature: 37°C– 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 rutinHemoglobinHematokritLeukositTrombosit
13,2-17,333-455.000-10.000150.000-440.000
15 g/dL44 %11800/uL267.000/uL
Fungsi GinjalUreum darahCreatinin darah
20-400,6-1,5
34 mg/dL0.9 mg/dl
DiabetesGula darah Puasa
80-100
95 g/dL
Standart value Result
Fungsi HatiSGOTSGPT
0-340-40
19 mg/dL19 mg/dl
ElektrolitNaKCl
135 – 1473.1-5.195-108
1334.8103
HemostasisAPTT / controlPT / controlINR
28.8/31.5 = 0.8912.1/13.5 = 0.890.87
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 REPORTHerniotomy + 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 patient’s fully concious• Ceftriaxone 2x1 gr• Ketorolac 3x30 mg• Omeprazole 2x40 mg
THANK YOU