EMERGENCY SURGICAL SERVICES

Wednesday, June 14, 2017

Consultant On Site :
Dr. Nur Rachmat Lubis, SpOT
The Attending Doctor :
Chief : dr. Andri Adinata
Chief OK : dr. Zulfikar
OK : dr. Zieky
dr. Hero Akbar
P1 : dr. Andri Soelistyo
dr. M. Roby S.
P2/P3 : dr. Fredy Ferdinand Carrol
dr. Bela Ronaldoe
HCU : dr. danny Amos Tarigan
Ward : dr. Ahmad Hari Kuncoro
dr. Hendry Dimas Putra Fajar
Traumatic patient : 5 patient
Non traumatic patient : 7 patient
Total : 12 patient
 TRAUMA CASES (5)

1. Rahman bin Sohar / / Years Old

D/ Chemical burn injury (cuka para) 36 %

2. Aswadi bin Malian/ / 55 Years Old

D/ Chemical burn injury (cuka para) 12%

3. Ahmad Teri Maulana/ / 8 Years Old

D/ Fire Burn injury grade IIA-B 8%

4. Amar Amri Pradana/ / 18 Years Old

D/ Moderate head injury of GCS 10 + cerebral edema

5. M. Febriansyah/ / 14 Years Old

D/ Moderate head injury of GCS 12 + cerebral edema
 NON TRAUMA CASES(7)

1. Homidi Anang/ / 71 Years Old

WORKING DIAGNOSIS
Urine retention (R33.9)
PRIMARY DIAGNOSIS
Suspect BPH
SECONDARY DIAGNOSIS
Hipertension
COMPLICATION DIAGNOSIS
Bilateral Hydronephrosis (N13.2)

2. Lika Atmajaya/ / 16 month Old

D/ Hydrochepalus with VP shunt expose
 NON TRAUMA CASES(7)

3. Rolita binti Herman/ / 16 month Old

D/ Suspect Hirschsprung Associated Enterocolitis

4. Isti Waidah/ / 40 Years Old

WORKING DIAGNOSIS
Gross hematuria, Obstructive Nefropathy
PRIMARY DIAGNOSIS
Suspect metastatic of Endometrioid carcinoma
SECONDARY DIAGNOSIS
Endometrioid Carcinoma post HTSOB post chemotheraphy,
hypertension
COMPLICATION DIAGNOSIS
Bilateral Hydronephrosis, Anemia (N13.2)
CKD Stage V
 NON TRAUMA CASES(7)

5. Mira Asmara/ / 24 Years Old

D/ Meckles diverticle + Ileal Band

6. Urip Atmorejo/ / 73Years Old

D/ Gastric Perforation at corpus site

7. Erlan Saidina Pratosa/ / 50 Years Old

D/ decreasing of consiousness due to non hemorhagic CVD
TRAUMA CASES
1. Rahman bin Sohar / / Years Old
Admitted on Wednesday, June14th 2017 at 1.20 pm

ANAMNESIS
Chemical burn injury
He got poured by chemical fluid on his face, chest, and back by
his wife
(about 3 days before admission)
(Reffered from AR Bunda Hospital)

PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. BP : 130/80 mmHg
PR : 88 x/mnt
T : 36,8 C
D. GCS : E4M6V5: Pupil Isochor, Light Reflexes +/+
SECONDARY SURVEY

There was chemical burn injury on

head :3%
Thoracoabdominal : 10 %
Right arm :7%
Left arm :8%
Thorax posterior : 8 %
Total : 36 %
LABORATORY FINDING
Hb : 15,5 gr/dl (12-16 gr/dl)
Ht : 44 vol % ( 40-48vol%)

DIAGNOSIS
Chemical burn injury (cuka para) 36 %

MANAGEMENT
Irigation
IVFD RL gtt 50 / m
Inj Ceftriaxon 1gram/ 12 hours IV
Inj Ketorolac 30mg/ 8 hours IV
Inj Ranitidin 50mg/ 12 hours IV
Inj ATS 1500 IU IM

Patient was treated in the ward

2. Aswadi bin Malian/ / 55 Years Old
Admitted on Wednesday, June 14th 2017 at 9.55 pm
ANAMNESIS
Chemical burn injury
He got poured by chemical fluid on his face, chest, and back by
someone
(about 3 hours before admission)

PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. BP : 120/70 mmHg
PR : 80 x/mnt
T : 36,5 C
D. GCS : E4M6V5: Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY

There was chemical burn injury on

head :1%
Thoracoabdominal :8%
Right arm :1%
Left Arm :1%
Thorax posterior :1%
Total : 12%
LABORATORY FINDING
Hb : 10,6 gr/dl (12-16 gr/dl)
Ht : 33 vol % ( 40-48vol%)

DIAGNOSIS
Chemical burn injury (cuka para) 12%

MANAGEMENT
IVFD RL gtt 30/m
Inj Ceftriaxon 1gram/ 12 hours IV
Inj Ketorolac 30mg/ 8 hours IV
Inj Ranitidin 50mg/ 12 hours IV
Inj ATS 1500 IU IM
Irigation

Patient was treated in the ward

3. Ahmad Teri Maulana/ / 8 Years Old
Admitted on Thursday, June 15th 2017 at 01.22 am

ANAMNESIS
Fire Burn injury
He got burned when he was playing with matches
(about 12 hours before admission)

PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. PR : 90 x/mnt
D. GCS : E4M6V5: Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY

There was chemical burn injury on

Right thigh :7%
genitalia :1%
Total : 8%
LABORATORY FINDING
Hb : 17,7 gr/dl (12-16 gr/dl)
Ht : 52 vol % ( 40-48vol%)

DIAGNOSIS
Fire Burn injury grade IIA-B 8%

MANAGEMENT
IVFD RL gtt XV / m
Inj Ceftriaxon 500mg/ 12 hours IV
Inj Paracetamol 250mg/ 8 hours IV
Inj ATS 1500 IU IM
Pro debridement

Patient was treated in the ward

4. Amar Amri Pradana/ / 18 Years Old
Admitted on Thursday, June 15th 2017 at 2.55 am
ANAMNESIS
Decrease of consiousness after having a trafic accident
the motorcycle that he drive hit a car from the opposite direction.
He fell with head hit a hard thing
(about 13 hours before admission)
Refered from prabumulih Hospital

PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. BP : 110/80 mmHg
PR : 82 x/mnt
T : 36,5 C
D. GCS : E2M5V3: Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY

On the frontal region

I : hematom (+)
P : Step Off (-)

On the parietooccipital region

I : hematom (+)
P : Step Off (-)
Head X-Ray AP/ Lateral
Fracture (-)
Head X-Ray AP/ Lateral
Fracture (-), cerebral edema
LABORATORY FINDING
Hb : 12,2 gr/dl (12-16 gr/dl)
Ht : 34,6vol % ( 40-48vol%)

DIAGNOSIS
Moderate head injury of GCS 10 + cerebral edema

MANAGEMENT
O2 10L/m
Head up 30
NGT
IVFD NaCl 0,9% gtt XX/minutes
Inj ceftriaxon 1gram/12 hours IV
Inj Tramadol 100mg/ 12 hours IV

Patient was treated in the ward

5. M. Febriansyah/ / 14 Years Old
Admitted on Thursday, February 15th 2017 at 3.44am

ANAMNESIS
Decrease of consiousness after having a traffic accident
His motorcycle that he drive got slipped. He fell with head hit a
hard thing
(about 10 days before admission)
Refered from muara enim Hospital

PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. BP : 110/80 mmHg
PR : 88 x/mnt
D. GCS : E4M5V4 : 13, Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY

Right Temporal Region

I: Hematom (-)
P: Step off (-)
RADIOLOGY FINDING
CT scan (M. Rabain hospital) dr. Dila Siti Hamidah, SpRad
Cerebral edema
LABORATORY FINDING
Hb : 12,3 gr/dl (12-16 gr/dl)
Ht : 35 vol % ( 40-48vol%)

DIAGNOSIS
Moderate head injury of GCS 13 + cerebral edema

MANAGEMENT
O2 10L/minutes
Head up 30
IVFD NaCl 0,9% gtt XX/minutes
Inj ceftriaxon 1gram/12 hours IV
Inj Tramadol 100mg/ 12 hours IV

Patient was treated in the ward

NON TRAUMA CASES
1. Homidi Anang/ / 71 Years Old
Admitted on Wednesday, June 14th 2017 at 10.16 am

ANAMNESIS
Unable to urinate
About 6 hours before admission, she complained unable to
uninate, nausea (-), vomite (-), fever (-)
History of bloody spill on catheter isertion before
History of difficult to urinate since 1 year ago
History of weak stream urine (+)
History of night urinate (+) 6-10 /night (-)

VITAL SIGNS
Sense : CM
BP : 150/100 mmHg
PR : 90x/mnt
RR : 20 x/mnt
T : 36,6 C
PHYSICAL EXAMINATION :
On The Right CVA Region :
I : Bulged (-)
P: Pain (-)
On The Left CVA Region :
I : Bulged (-)
P: Pain (-)
On the suprapubic region
I : Bulging (+)
P : dull
On the genitalia externa region
I : bloody discharge(-)
Urethrogram
stricture (-) rupture (-) contras extravasation (-)
USG
Bilateral hydronephrosis
Full blast
USG TUG
(dr. Hanna Marshinta,SpRad)
Bilateral hydronephrosis
prostat hyperplasia
LABORATORY FINDING:
Hb : 14,2 g/dl ( 12-16 g/dl )
Ht : 43 vol % ( 37-43 vol % )
WBC : 13.700 / mm3 ( 5000-10000/mm3 )
Trombo : 285.000 / mm3 ( 200.000-500.000/mm3)
BSS : 115 mg/dl
Ureum : 34 mg/dl ( 15-39 mg/dl )
Creatinin : 1,60 mg/dl ( 0,6-1,0 mg/dl )
Na : 144 mmol/l ( 135-155 mmol/l )
K : 4,8 mmol/l ( 3,5-5,5 mmol/l )
WORKING DIAGNOSIS
Urine retention (R33.9)
PRIMARY DIAGNOSIS
BPH
SECONDARY DIAGNOSIS
Hipertension
COMPLICATION DIAGNOSIS
Bilateral Hydronephrosis (N13.2)

MANAGEMENT
- IVFD RL gtt XX/minute
- Inj Ceftriaxone 1 gr/ 12 hours IV
- suprapubic punction
- Cystostomi

Patient was treated in the ward

2. Lika Atmajaya/ / 16 month Old
Admitted on Wednesday, June 14th 2017 at 12.05 pm

ANAMNESIS
Increased head circumference
About 1 year ago her doughter head circumference getting larger
history of VP shunt 7 month ago
Patient often get fever and followed by seizure
Stomatch ache after VP shunt (+)

VITAL SIGNS
PR : 102 x/mnt
RR : 30 x/mnt
T : 36,4 C
PHYSICAL EXAMINATION :
On The head Region :
I : macrocephalus (+)
VP shunt expose

On The abdominal Region :

I : flat
P : soft
P : timphani
A : Bowel Sound (+)
LABORATORY FINDING:
Hb : 10,8 g/dl ( 12-16 g/dl )
Ht : 32 vol % ( 37-43 vol % )
WBC : 9.100 / mm3 ( 5000-10000/mm3 )
Trombo : 384.000 / mm3 ( 200.000-500.000/mm3)

DIAGNOSIS
Hydrochepalus with VP shunt expose

MANAGEMENT
- IVFD D5 NS gtt X/m
- Inj Ceftriaxone 250 mg/ 12 hours
- Inj Paracetamol 100mg/8 hours
- Remove VP shunt
INTRA OPERATIVE
We found VP shunt expose, we perform lazy-s incision on two
side
We perform VP shunt removal
Continued with refreshing and undermining

Patient was treated in the ward

3. Rolita binti Herman/ / 16 month Old
Admitted on Wednesday, June 14th 2017 at 12.50 pm

ANAMNESIS
Abdominal Distended
About 1 year before admission his mother complained her
doughter stomach getting distended. Vomite (+) since 4 days
before admission, the content is what she drink
Diarhaea (+) since 4 days before admited
fever (-), history of late meconium (+), history of constipation (+)
Refered from Kayu Agung Hospital

VITAL SIGNS
PR : 92x/mnt
RR : 24 x/mnt
T : 36,5 C
PHYSICAL EXAMINATION :
On The abdominal Region :
I : Distended
P : Soft
P : Timphani
A : Bowel Sound (+)

DRE:
Sprouting stool
LABORATORY FINDING:
Hb : 12,3 g/dl ( 12-16 g/dl )
Ht : 35 vol % ( 37-43 vol % )
WBC : 19.600/ mm3 ( 5000-10000/mm3 )
Trombo : 421.000 / mm3 ( 200.000-500.000/mm3)

DIAGNOSIS
Suspect Hirschsprung Associated Enterocolitis

MANAGEMENT
IVFD D5 NS gtt 40/m (mikro)
- Inj Ceftriaxone 250 mg/ 12 hours
- Inj metronidazole 100mg / 8 hours
- Rectal wash out
4. Isti Waidah/ / 40 Years Old
Admitted on Wednesday, June 14th 2017 at 1.10 pm

ANAMNESIS
Bloody urinate
About 10 days before admission she complain bloody urinate
and difficult to urinate.
History of histerectomy June, 2016 at RSUP dr. Mohammad
Hoesin Palembang
PA : Endometrioid carcinoma grade II at uterus that covered
upper third cervix, all uterus lower segment, and a half of
myometrium
History of chemotherapy, 6x untill December, 2016
History of hipertension since 1 year ago
.
VITAL SIGNS
Sense : CM
BP : 140/110 mmHg
PR : 82x/mnt
RR : 22 x/mnt
T : 36,6 C
PHYSICAL EXAMINATION :
On The abdominal region:
I : flat, operation scar(+)
P : soft
P : timphani
A : Bowel sound (+)
On The Right CVA Region :
I : Bulged (-)
P: Pain (-)
On The Left CVA Region :
I : Bulged (-)
P: Pain (-)
On the suprapubic region
I : Bulging (-)
P : dull (+)
On the genitalia externa region
I : bloody discharge(-)
USG (IGD)
Bilateral hydronephrosis
CT SCAN (17 february 2017)
right hydronefrosis + right upper hydroureter
LABORATORY FINDING:
Hb : 8,9 g/dl ( 12-16 g/dl )
Ht : 26 vol % ( 37-43 vol % )
WBC : 12.400 / mm3 ( 5000-10000/mm3 )
Trombo : 453.000/ mm3 ( 200.000-500.000/mm3)
BSS : 98 mg/dl
Ureum : 123 mg/dl ( 15-39 mg/dl )
Creatinin : 11,8 mg/dl ( 0,6-1,0 mg/dl )
Na : 151mmol/l ( 135-155 mmol/l )
K : 4,1 mmol/l ( 3,5-5,5 mmol/l )
WORKING DIAGNOSIS
Gross hematuria, Obstructive Nefropathy
PRIMARY DIAGNOSIS
Suspect metastatic of Endometrioid carcinoma of Bladder
SECONDARY DIAGNOSIS
Endometrioid Carcinoma post HTSOB post chemotheraphy,
hypertension
COMPLICATION DIAGNOSIS
Bilateral Hydronephrosis, Anemia (N13.2)
CKD Stage V

MANAGEMENT
- IVFD RL gtt XX/minute
- Inj Ceftriaxone 1 gr/ 12 hours
- 3 way catheter irigation
- transfusion
- Plan to right nephrostomi
- Join Care Internal Department: pro Hemodialisa

Patient was treated in the ward

5. Mira Asmara/ / 24 Years Old
Admitted on Wednesday, June 14th 2017 at 3.40 pm

ANAMNESIS
Abdominal distended
Since 1 week before admission the patient complain of
Abdominal distended, defecate (-), flatus (-), vomites (+), fever (-)
History of bowel change habit (-), decreasing of body weight (+)

VITAL SIGNS
Sense : CM
BP : 110/90 mmHg
PR : 108x/mnt
RR : 24 x/mnt
T : 37,1 C
PHYSICAL EXAMINATION :
On The abdominal region:
I : dome shape, bowel contour (+)
bowel movement (+)
P : soft
P : timphani
A : Bowel sound (+) increase

DRE:
I : TSA was good, ampula colaps,
smooth mucosa, no palpable mass
USG
(Sekayu Hospital) dr. Agnes, SpRad
Ileus
sludge gall blader
X-Ray
Plain abdominal X Ray

Bowel distention (+)

Herring Bone (+)
Air Fluid Level (+)
Free Air (-)
LABORATORY FINDING:
Hb : 13,9 g/dl ( 12-16 g/dl )
Ht : 43 vol % ( 37-43 vol % )
WBC : 13.900 / mm3 ( 5000-10000/mm3 )
Trombo : 646.000/ mm3 ( 200.000-500.000/mm3)
BSS : 98 mg/dl
Ureum : 53 mg/dl ( 15-39 mg/dl )
Creatinin : 0,5 mg/dl ( 0,6-1,0 mg/dl )
DIAGNOSIS
High level bowel obstruction
Sepsis

MANAGEMENT
- IVFD RL gtt XX/minute
- Inj Ceftriaxone 1 gr/ 12 hours IV
- inj Metronidazole 500mg/ 8hours IV
- inj Ranitidin 50 mg/ 12 hours IV
- fasting
- NGT, Catheter
- Laparotomy exploration

Patient was treated in the ward

INTRAOPERATIVE
We found distended small bowel
We found band 20cm from ICJ and diverticle meckle 60 cm from
ICJ
We release the band and we found Necrotic Meckle diverticle,
We decide to resect ileum from 20 cm until 60 cm from ICJ
Continued with ileostomy mucofistule

POST OPERATIVE DIAGNOSE

Meckles diverticle + Ileal Band

Patient was treated in the ward

6. Urip Atmorejo/ / 73Years Old
Admitted on Thursday, February 15th 2017 at PM
ANAMNESIS
Pain on whole abdomen
Since 7 days before admission patient complain of pain on his
epigastric region.
Since 3 days before admission patient complain of pain on his
whole abdomen
History of melena (+) 1 month ago
History of analgetik consumption since 1 year ago

VITAL SIGN
Sens : CM
TD : 130/80 mmHg
N : 96 x/mnt
RR : 21 x/mnt
T : 36,5C
PHYSICAL EXAMINATION

On the abdominal Region

I: flat
P: muscular rigidity (+)
P: deminished of liver dull
A: bowel sound (+) decrease
RADIOLOGY FINDING
USG Emergency
Free fluid (+)
RADIOLOGY FINDING
X-Ray
Free Air (+)
LABORATORY FINDING
Hb : 11 gr/dl (12-16 gr/dl)
Ht : 36 vol % ( 40-48vol%)
Leukosit : 3.600 /mm3 (5000-10000/mm3)
Trombosit : 538.000 /mm3 (150.000-450.000/mm3)
Diff. Count : 0/0/91/4/5
Albumin : 2,6 mg/dL (3,5-5,5 mg/dL)
Ureum : 174 mg/dL (16.6-48.5 mg/dL)
Kreatinin : 4,96 mg/dL (0.70-1.20 mg/dL)
BSS : 111 mg/dL (>200mg/dL)
Natrium : 141 mEq/L (135-155 mEq/L)
Kalium : 6,1 mEq/L (3.5-5.5 mEq/L)
DIAGNOSIS
Diffuse Peritonitis due to hollow viscous organ perforation + AF
ventricular rapid respon + Susp lung TB + Hyperkalemia

THERAPY:
IVFD RL gtt XXX/minute
- Inj Ceftriaxone 1 gr/ 12 hours IV
- inj Metronidazole 500mg/ 8hours IV
- inj Ranitidin 50 mg/ 12 hours IV
- fasting
- Electrolite correction
- Digoxin 0,25 mg
- Amiodaron 100mg (drip)
- Laparotomy exploration

patient was treated in the ward

INTRA OPERATIF
We found gastric content 200 cc which came out from
gastric perforation on the corpus site, 0,5 cm in size
We perform freshening the edge of perforation PA
we suture the perforation continously with PGA 3.0 rounded
we put 1 drain subhepatic

POST OPERATIF DIAGNOSIS

Gastric Perforation at corpus site

Patient was treated in the ICU

7. Erlan Saidina Pratosa/ / 50 Years Old
Admitted on Wednesday, February 14th 2017 at 10.09 PM
ANAMNESIS
Consult from neurology departement
Decreasing of consiousness suddenly since 1 day before
admission
History of half body weakness right side since a week, lisp talk

VITAL SIGN
Sens : E2M3VT : 5T
TD : 150/100 mmHg
N : 94 x/mnt
RR : 20 x/mnt
T : 36,5C
RADIOLOGY FINDING
CT cranium
Hipodens lession at left hemispher
DIAGNOSIS
Decreasing of consiousness of GCS 5T due to non hemorhagic
CVD

THERAPY:
O2 10L/minutes
Head up 30
IVFD NaCl 0,9% gtt XX/minutes
Inj ceftriaxon 1gram/12 hours IV
Inj Tramadol 100mg/ 12 hours IV
Craniectomy decompression

patient was treated in P1

EMERGENCY REPORT
1. Jessica/ / 13 Years Old
Admitted on tuesday, February 13th 2017 at 10.53 PM

PREOPERATIF DIAGNOSIS
Acute appendicitis

INTRA OPERATIF
We found appendix that inflammed at pelvinal site
We perform appendektomi

POST OPERATIF DIAGNOSIS

acute appendicitis

Patient was treated in the ward

2. Fatima binti Likun/ / 43 Years Old
Admitted on Wednesday, February 14th 2017 at 1.44 PM

PREOPERATIF DIAGNOSIS
G6P3A2 32 weeks gravid with head presentation fetus+ DKP +
anhidramnion + PEB

INTRA OPERATIF
Blader mucosa we suture with 3.0 plain continous
Blader seromuscular we suture with 3.0 PGA interupted

POST OPERATIF DIAGNOSIS

P3A3 32 weeks gravid post SSTP + DKP + anhidramnion + PEB + post
right tubectomy + post adhesiolisis + Iatrogenic bladder rupture +
haemorrhagic shock
Patient was treated in the ICU
THANK YOU