Duty Report

Saturday, 25th March 2017

General-Surgery Resident : Filipus
Dasawala, M.D.
Surgical interns : Angel, Deza, Kiki, Yuni
 Attending surgeons on
call
Pediatric surgery : Irhamni, M.D., SpB, SpBA
Digestive surgery : Tan Suhardi, M.D., SpB-KBD
Orthopedic surgery : Djamaludin Wijaya, M.D., SpOT
Plastic & Reconstructive surgery : Anastasia Dessy Harsono, M.D.,
SpBP (RE)
Neurologic surgery : Handrianto Setiajaya, M.D., SpBS
Oncologic surgery : Marina T Gultom, M.D., SpBOnk
TCV surgery : Arief Widya Taufik, M.D., SpBTKV
Urologic surgery : Nindra Prasaja, M.D., SpU
Patients recapitulation
Total
Outpatient 1
Inpatients 2
Operation 0
 Outpatient
No Name Age MR Diagnosis Management
1 PM 26 850129 1. Blunt chest Chest X-ray
y.o. trauma Abdominal
2. Blunt USG
abdominal Analgesic
trauma
 Inpatients
No Name Age MR Diagnosis Management
1 MM 25 850134 1. Severe ICU admission
y.o. Traumatic Brain IVFD
Injury NGT
2. Multiple facial Antibiotic
fractures Analgesic
Neuroprotector
Elective facial
reconstruction
 Inpatients
No Name Age MR Diagnosis Management
2 RS 52 850139 1. Decreased ICU admission
y.o. consciousness NGT
level due to Antibiotics
sepsis Analgesic
2. Pneumoperitone PPI
um due to Consult to
perforation of Neurology
viscus Consult to
3. Sepsis Internist
4. AKI
5. Cardiomegaly
Inpatients
1
Inpatient
Ms. FA, 25 y.o., 85-01-34
CC: Motor vehicle accident
History of present illness:
5 days prior to hospital admission, the patient was in a motor
vehicle accident. The patient was sitting the front passenger
seat. The car that she was in hit another car when it was
trying to overtake the car in front of it from the left side. The
patient was never fully conscious after the collision. After 5
days in the ICU, the patient was referred from Multazam
Medika Hospital, Bekasi because of the unavailability of a
neurosurgeon and a plastic surgeon. There was no worsening
nor improvement in her consciousness. There was no seizure.
Inpatient
Ms. FA, 25 y.o., 85-01-34
History of past illnesses: there was none.
Physical findings
Primary survey
A : Clear, Neck collar
B : Spontaneous, tachypnea
C : Warm extremities, strong pulse
D : E2M4V2
E : No hypo-/hyperthermia
Physical findings
BP: 140/78 mmHg, PR: 92 tpm, RR 22 tpm, t: 37.1C
Face : Swollen left cheek and laceration on the left
lateral epichantus ( 2 cm laterally)
Eye: Isocoric pupil 2 mm, direct and indirect pupillary
reflexes (+), subconjunctival bleeding on the left eye
Neck : Neck collar was on
Lungs : Vesicular breath sounds
Heart : Normal 1st and 2nd heart sounds
Physical findings
Abdomen : Flat, bowel sound (+)
Extremities : Warm, CRT <2
Physical findings
Physical findings
Supporting findings
Laboratory
Hgb/Hct : 11.1 g/dl /31%
Leukocyte : 11,720 /L
Platelet : 268,000 /L
PT/aPTT :
Albumin : 3.5 g/dL
Ur/Cr : 6 mg/dL ; 0.4 mg/dL
RBS : 88 mg/dL
Na/K/Cl/Ca/Mg : 137 mmol/L; 3.4 mmol/L; 105 mmol/L;
8.4 mmol/L ; 2.24 mmol/L
Supporting findings
Laboratory
pH : 7.362
pCO2 : 36.6 mmHg
pO2 : 187.2 mmHg
(HCO3)- : 16.7 mmol/L
BE : -4.5
SaO2 : 97.2%
Supporting findings
Cranio-cerebellar CT-Scan Images
Supporting findings
Cranio-cerebellar CT-Scan
Working Diagnosis
1. Severe Traumatic Brain Injury
2. Closed fracture of the lateral and inferior orbital rim of
the left eye; Closed fracture of the zygomaxillary
complex;
Closed fracture of the body and rami of the left
mandible,
Closed fracture of the body and rami of the right
mandible.
Management
1. ICU admission
2. IVFD
3. NGT
4. Antibiotic
5. Analgesic
6. Neuroprotector
7. Elective facial reconstruction
Her condition today
Inpatients
2
Inpatient
Mrs. RS, 52 y.o., 85-01-39
(alloanamnesis)
CC: Right upper to left upper quadrant abdominal pain
Present history of illness:
5 days prior to hospital admission, the patient was said to be
complaining of right upper to left upper quadrant abdominal
pain. There were no further information regarding the pain.
Then the patient was brought to St. Carolus Hospital.
2 days prior to hospital admission, the patient was said to be
having decreased consciousness. The patient was referred
due to the unavailability of ICU with suspicion of gastric
perforation.
Inpatient
Mrs. RS, 52 y.o., 85-01-39
(alloanamnesis)
History of past illnesses:
CHF fc III due to CAD and HHD
Pneumonia
Anemia
Atrial fibrillation normoresponse
Physical findings
BP: 180/100 mmHg, PR: 105 tpm, RR 20 tpm, t: 38.9C
Eye: Isocoric pupil 2 mm, direct and indirect pupillary
reflex (+)
Lungs : Vesicular breath sounds
Heart : Normal 1st and 2nd heart sounds
Abdomen : Distended, bowel sounds (+),
abdominal guarding (-), liver dullness (+)
Anus : normal AST, ampulla was not collapsing,
smooth mucosa (+), no mass was palpable, gloves
(faeces)
Supporting findings
Laboratory
Hgb/Hct : 10 g/dl /32%
Leukocyte : 15,130/L
Platelet : 390,000/L
PT/aPTT : 1.4x; 1.19x
AST/ALT : 22 U/L; 9 U/L
Albumin : 3.5 g/dL
Ur/Cr : 168 mg/dL/3.3 mg/dL
RBS : 163 mg/dL
Na/K/Cl : 138 mmol/L; 4.6 mmol/L; 108 mmol/L
Supporting findings
Laboratory
pH : 7.296
pCO2 : 19.6 mmHg
pO2 : 22.0 mmHg
HCO3 : 9.6 mmol/L
BE : -13.8
SaO2 : 99.7%
Supporting findings
Abdominal CT-Scan Images
Supporting findings
Abdominal CT-Scan Images
Supporting findings
Abdominal CT-Scan Images
Working Diagnosis
1. Decreased consciousness level due to sepsis
2. Pneumoperitoneum due to perforation of viscus
3. Sepsis
4. AKI
5. Cardiomegaly
Management
1. ICU admission
2. NGT insertion
3. Meropenem 1 gr t.i.d.
4. Metronidazole 500 mg t.i.d.
5. Paracetamol 1 g t.i.d.
6. Omeprazole 200 mg/24 h
7. Consult to Neurology
8. Consult to Internist
Her condition today
Although I only entertained these
patients during my duty
I do appreciate your attention