Tuesday, May 14th 2019

KBN/BAY/SEL/DTA/ADP/WHS/YDA/AFI/AAM/FRZ
In Emergency Installation we received … patients, consist of :
No Diagnose Planing
SOL of left temporal region GCS Oxygenation
E1M4V1 Head up 30º
Right lung tumor (suspected NGT application
malignancy) Urethral catheter application
Manitol initiation loading 250 cc 
maintenance 125 cc/ 6 hours
intravenous
Dexamethasone 10 mg/ 8 hours
intravenous
Ranitidine 50 mg/ 12 hours intravenous

 1 patient  GerD
No Diagnose Planing

Mild head injury with GCS Oxygenation

E4M6V5=15 (S09.9) Head up 30º
Suspected impression fracture of Ketorolac 30 mg/ 8 hours intravenous
right temporo-parietal region
(S02.0)
Suspected uncomplicated closed
fracture of right clavicle (S42.0)

 1 patient  C1LD

ICH of left frontal region (volume Oxygenation

70 cc) with GCS E1M1Vet (I61.9) Head up 30º
SAH suspected rupture aneurysm NGT application
(S06.6) Urethral catheter application
Manitol 250 mg intravenous 
maintenance 125 mg/ 6 hours intravenous
Ranitidine 50 mg/ 12 hours intravenous
Head MSCT without contrast

 1 patient  ER
No Diagnose Planing

Severe head injury with GCS Oxygenation

E1M4V1=6 (S09.9) Head up 30º
Suspected fracture of cranial base Collar neck application
(S02.1) Urethral catheter application
Suspected pulmonary contusion Ketorolac 30 mg/ 8 hours intravenous
(S27.3) MSCT Craniocerebral
X-ray cervical AP/Lat
X-ray thorax

 1 patient  ER
No Diagnose
IIIc grade of segmental displaced
open fracture on 1/3 middle of
right tibial bone (S82.2)
IIIc grade of segmental displaced
open fracture on 1/3 middle of
right fibula bone (S82.4)
IIIc grade of transverse displaced
open fracture on 1/3 distal of right
femur bone (S72.8)
Planing
Wound toilet
Suturing
Splinting application
Ampicillin sulbactam 1,5 gr/ 8 hours
intravenous
Gentamycin 80 mg/ 24 hours intravenous
Ketorolac 30 mg/ 8 hours intravenous
Hip X-ray AP
Right upper leg X-ray AP/Lat
Right lower leg X-ray AP/Lat
Right foot X-ray AP/Lat

 1 patient  R2B
Pericard effusion after MVR (30-04- Oxygenation
2019) (I31.3) Pericardiocentesis elective

 1 patient  ElangII
No Diagnose Planing
Partial ileus obstructive (K56.7) Observation
P1A0 after SCTP 5 day before Liquid dietary
admission (Z39.2) Ciprofloxacin 400 mg/ 12 hours
Wound dehiscense (T81.3) intravenous
Metronidazole 500 mg/ 8 hours
intravenous
2 position of BNO
Debridement elective
Laparotomy exploration

 1 patient  HCU
No Diagnose Planing
Abdominal pain (R10.9) DD/ Ciprofloxacin 400 mg/ 12 hours
CBD stone (K80.5) with history intravenous
of cholesistectomy (2016) ec Metronidazole 500 mg/ 8 hours
cholecystolithiasis (K80.8) intravenous
Omeprazole 40 mg/ 12 hours
intravenous

 1 patient  ER
Low output enterocutan fistula Keep warmth
(K63.2) Colostomy bag application
Cefotaxime
Metronidazole

 1 patient  Garuda II 3rd floor

No Diagnose Planing
Right invasive ductal ca Oxygenation
mammae local recidive Right pleural water sealed drainage
T4aN3cM1 elective
Right pleural effusion

 1 patient  MRK2

Urinary retention (R33.9) ec Urethral catheter application

neurogenic bladder (N31.9) Mefenamic acid 500 mg/ 8 hours orally

 1 patient  Discharged
 Tuesday, May 14th 2019
KBN/BAY/SEL/DTA/ADP/WHS/YDA/AFI/AAM/FRZ
CASE REPORT (17.40)
A male, 62 years old, consulted from Cardiology with chief complain
dispneu, already brought cardio ultrasonography inserted intravenous
line sodium chloride 0,9% 20dpm.
H.O.I:
± 1,5 months ago patient patient got hemoptyisis with lost in weight,
he came to puskesmas and diagnosed with lung tuberculosis. He got
medication for lung tubercolosis.
± 10 days ago he felt his stomach became bulging and difficulty in
breathing. Because of that complaint he was taken to RSUD
Soewondo Pati and treated for 7 days. On examination show he got
pericardial effusion
± 1 day before admission patient feel more difficult in breathing
then patient was refered to RSUP dr. Kariadi
Physical Examination
General condition: Alert, look dispneu
RR : 28 x/mnt (regular)
SpO2 : 99 %
BP : 95/67 mmHg
PR : 84 x/mnt ( regular, adequate tone and volume )
T : 36,5 C
Head : Mesocephal, injury mark (-)
Eyes : Palpebra conjunctiva wasn’t pale
Equal pupil  3mm, LR (+)/(+)
Neck : No injury mark, JVP was increase, trachea in the middle
Chest : injury mark (-)
Heart: I : ictus cordis was not seen, injury mark (-)
Pa : ictus cordis palpated on 5th intercostal space, 2 cm
from medial mid clavicle line
P : Configuration within normal limits
A : Pure heart sound, no additional sound

Lung : I : Static : right hemithorax = left hemithorax

Dynamic : right hemithorax = left hemithorax
Pa : Tactile fremitus (+/+)
P : Sonor all around area
A : Vesicular, additional sound (-)
Abdomen :
I : Flat
P : Smooth,no tenderness,no muscle rigidity
P : Timpanic, LD (+), FD (+), SD (-)
A : Bowel sound (+) wnl

Pelvic : injury mark (-), deformity (-)

External Genitalia : male, wnl
Anoperineal : wnl

Extremity Sup Inf

cold acral -/- -/-
app refill <2” <2”
Motoric +/+ +/+
Sensoric +/+ +/+
Working diagnosis (17.50):
Massive pericardial effusion
Initial Management (16.22) :
•IPDx :
• S :-
• O :-

•IPTx :
• Oxygen 3 lpm nasal canule
• Infusion lactat ringer 20 dpm
• Pericardial window cito

•IPMx :
• Complaint, general condition, vital sign, routine blood
examination, Ureum/Creatinin, electrolyte and coagulation time
test
• IPEx :
• Informed consent, diagnosis, management and prognosis
Laboratory study (RSUP dr.Kariadi / August 07th 2018 ):

Hb : 11,7 gr% (13,00 – 16,00)

Ht : 38.6 % (40 – 54)
L : 13.5 /mmk (3.800 – 10.600)
Tr : 332.000 /mmk (150.000 – 400.000)
GDS : 95 mg/dl (80 – 160)
SGOT : 54 U/L (15 – 34)
SGPT : 93 U/L (15 – 60)
Ureum : 24 mg/dL (15 – 39)
Creatinin : 0,7 mg/dL (0,60 – 1,30)
Magnesium : 1,10 mg/dl (0,74 – 0,99)
Calcium : 2,0 mg/dl (2,12 – 2,52)
Na : 138 mmol/L (136 – 145)
K : 4,4 mmol/L (3,5 – 5,1)
Cl : 100 mmol/L (98 – 107)
PPT/K : 15,3 / 11,3 second
PTTK/APTT : 49,6 / 34,1 second
INR : 1,46
Echocardiography study ( RSUD Soewondo Pati / 30th july 2018)
Diagnosis (16.30):
Massive pericardial effusion
Lung Tuberculosis on going treatment
Management (16.35) :
•Dx :
• S :-
• O :-
•Tx :
• Pericardial window cito
• Mx :
• Complaint, general condition, vital sign
• Ex :
• Informed consent, diagnosis, management and prognosis
Operation report (00.05-00.40) :
- Patient lied with fowler position under GA
- Operation area was dissinfected, narrowed with sterile clothes
- Make incision on 5th ICS below left nipple
- Depend incision until pericardium, finding thick pericardium
- Aspiration with nedle, there is no fluid
- incisi pericardium make histophatologis examination
- Sutured operation wound layer by layer
- Operation finished
Post operative diagnosis (00.45) :
Massive pericardial effusion
Lung Tuberculosis on going treatment
 Post pericardial window
Management post operation (03.00) :
• Dx :
• S:-
• O:-
• Tx :
• RL 20 drops/minute
• Ceftriaxone 2 gram/24 hour intravenous
• Ketorolac 30 mg/8 hours intravenous
• Wound care using moist gauze
• Mx :
• General condition, complain, tissue vitality, study coagulation
• Ex :
• Prognosis, operation finding
 Tuesday, May 14th 2019
KBN/BAY/SEL/DTA/ADP/WHS/YDA/AFI/AAM/FRZ