Night Shift Report

Saturday, July 22nd 2017

Consultant on duty : Dr. dr. Shinta Fitri Boesoirie, MKes,

Sp.T.H.T.K.L (K)
Chief on duty : dr. Ichsan
Doctor on duty : dr. Sari
dr. Riri
dr. Frino
 Male, 50 years old
Patient consulted from Oral Surgery Departement with
WD/ Sepsis + Post Incision and drainage at regio Submandibular
Sinistra et Submental on indication Submandibula Abcess
Sinistra which extends to the buccal POD 6 + Acute Kidney Injury
Chief complain : Difficult to open mouth
The patient had been performed a drainage incision 6
days ago. The patient planned for exploration and re-drainage
incision in general anesthesia and suggested by anesthesiologist
for consult to ENT due to difficult intubation.
 The patient was having difficulty in opening
the mouth since 3 days ago,
 PHYSICAL EXAMINATION
General State:
Compos Mentis, inspiration Stridor (-), Suprasternal Retraction (-) Epigastrium Retraction
(-) intercostal Retraction (-)

BP: 110/60 mmHg, HR: 110 x/m PR: 80 x/m

RR: 24 x/m T : 36,7o C
O2 Sat : 98% without oxygent support
ORL-HN State:
- Both ears : CAE not hyperemic, secret -/- , cerumen -/-,ear
drum intact +/+, cone of light +/+, retroauricular
not hyperemic : +/+
- CN : Mucosa not hyperemic +/+, discharge -/-, inferior
turbinate : eutrophy +/+, SD (-), air passage :+/+
- NPOP : Interdental Opening 1 cm, others are difficult to evaluate
- MF : Assymetrical, a/r buccal dextra : swelling (+), hyperemic (-),
Fluctuation (-) ,tenderness (-)
a/r Colli : Post incision drainage wound covered by bandage
- Neck : neck node enlargement (-)
Clinical Picture
 Laboratory Findings
Hb : 13,4 gr/dl Mg : 2.0
WBC : 21.040/mm3 PT/aPTT : 15,8/33,5 sec.
Ht : 39,7% INR : 1,49
Plts : 496.000/mm3 Blood glucose : 102 mg/dl
SGOT/SGPT : 42/45 IU/L pH : 7,474
Ur/Cr : 41,0/0,71mg/dl pO2 : 197,8i
Na : 145 pCO2 : 27,6
K : 4.0 HCO3 : 20,4
Cl : 106
tCO2 : 21,3
Ca : 3.40
BE : -1,2
Neck Soft Tissue X-ray
Thorax X Ray
WD/ Sepsis + Post Incision and drainage at regio Submandibular
Sinistra et Submental on indication Submandibula Abcess Sinistra
which extends to the buccal POD 6
Management :
Obs. of vital sign
O2 3 Lt/minute
Plan to perform Tracheostomy pre-op/LA
Others submitted to Oral Surgery Department
Had been perfomed tracheostomy/LA
(IJ/FI/RY)
DO :
Air passage via canul (+)
Bleeding (-)
Subcutaneous emphysema (-)
Sat O2: 99 %
WD/ Post Tracheostomy due to Trismus due to inflamation of
Masticator Muscle + Sepsis + Post drainage incision due to left
submandibular abscess and submental extend to right buccal + Acute
Kidney Injury
Management :
Obs. of vital sign
O2 3-4 Lt/minute via T-Piece
Keep the tracheostomy baloon inflate
N-Acetylsistein 3 x 200mg PO
Others submitted to Oral Surgery Department
 Male, 35 years old
Patient was referred from Sumber Waras Hospital of Cirebon with
WD/ Post Craniotomy POD IX due to depressed fracture + CCH +
SDH + Multiple fracture + Maxillary fracture + Mandibular
fracture
cc : Decreased consciousness
The patient had a motorcycle accident 9 days ago, collision
of a motorcycle. The patient helmet slipped then head and face hit
the asphalt. History of fainting (+), history of vomiting of blood (+),
history of ear and nose bleeding not known. Double vision
complaints (-), Nasal congestion (-). Patient can not eat, can only
drink using a straw. Left hand pain.
 Physical Examination
General state: Somnolen (GCS 13), BP : 110/80 mmHg, RR : 24 x/m
HR : 90 bpm , T : 37,3 C, stridor (-), retraction (-)
O2 saturation 98% with oxygen 3 lpm via nasal canul

Local state :
At regio frontoparietal dextra : deformity (+), cranium partially absent
Both ears : external auditory canal not hyperemic +/+ discharge
-/-, ear wax -/- ear drum intact +/+, cone reflex
+/+, right retro auricular deformity (+)/ left retro auricular
normal (+)
Nasal cavity : mucosa no hyperemic +/+, discharge -/-, inferior turbinate
eutropy +/+, septum deviation (-), air passage +/+
NPOP : To : T1-T1 not hyperemic, pharynx not hyperemic,
MF : at right eyebrow : primary suture (+)
at right zygoma : deformity (+), crepitation (-)
at right and left mandibula : deformity (+)
Neck : neck node (-), mass (-), bruise (-), crusta (-)
Clinical Picture
Chest X-Ray
CT Scan
3D CT Scan
3D CT Scan
 LABORATORY FINDINGS

Hb : 8,9 APTT : 21,6

Wb : 13.810 Ur : 39,0
Ht : 26,8 Cr : 0,76
Plt : 375.000 pH : 7,381
Blood glucose : 96 pCO2 : 41,8
SGOT : 36 pO2 : 41,3
SGPT : 53 HCO3 : 25,0
Na/K/Ca : 139/4,1/4,13 tCO2 : 26,3
PT : 10,5 BE : 0,5
INR : 0,97 SPO2 : 98,0
WD/: Post Craniotomy POD IX due to depressed
fracture + CCH + SDH + Multiple fracture +
Maxillary fracture + Mandibular fracture + Left
distal radius ulna fracture

Management :
Observation of awareness, vital sign
IVFD NaCl 0.9% 20 gtt/min
O2 3 L/minute via nasal canule
Complete lab check
X-ray STL AP + Lateral
Consult to Orthopedic Department
Consult to Neurosurgery Department
 Answers from Orthopedic Departement

X-ray forearm and left wrist joint AP/Lateral

Plan to perform elective ORIF
Immobilitation with spalk

Answer from Neuro surgery Department:

- Conservative
Thank You