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