Tuesday, 7th November 2017

In Emergency Installation we received 17 patients, consists of :

NO Diagnosis Plan
1. Excoriation wound (T14.0) : 1 pt Wound toilet
Mefenamic Acid 500 mg/8 hours orally
discharged
2. Laceration wound (T14.1) : 3 pt Wound toilet
Suturing
Amoxicyllin 500 mg/8 hour orally
Mefenamic Acid 500 mg/8 hour orally
discharged
3. Foreign body on right brachii Wound toilet
region (T14.1) : 1 pt Suturing
Corpal extraction
Amoxicyllin 500 mg/8 hour orally
Mefenamic Acid 500 mg/8 hour orally
discharged
NO Diagnosis Plan
4. Decubitus ulcer grade IV on Ciprofloxacin 500 mg/12 hour intravenous
right and left of trochanter femur Omeprazole 40 mg/12 hour intravenous
cb immobilization cb inferior Ketorolac 30 mg/8 hour intravenous
paraplegy cb susp. Vertebral Wound care with moist gauze
fracture cb traffic accident 1,5 NGT application
year ago (L89.3) R2A
Sepsis (A41)
Paralitic ileus dd obstruction
(K56.0)
: 1 pt
5. Multiple cerebral abcess (G06.0) : Join management with pediatric department
1 pt CILD

6. SOL on cerebropontine region Head Up 300

GCS E4M6V5 = 15 (R90.0) : 1 pt Oxygenation
Dexamethasone 10 mg/8 hour intravenous
Phenitoin 200 mg/24 hour intravenous
Ranitidine 50 mg/12 hour intravenous
Ketorolac 30 mg/8 hour intravenous
Parkit
NO Diagnosis Plan
7. Uncomplicated Comminutive Mefenamic Acid 500 mg/8 hour orally
Closed Fracture of Right Skin traction application
Trochanter Femur (S72.1) : 1 pt Ger D
8. CKD stage V on HD (N18.5) : 3 Double Lumen Application
pt R2B, R2B, GRD 2

9. Adenocarcinoma Mucinous of Omeprazole 40 mg/12 hour intravenous

Abdomen on Chemotherapy Ketorolac 30 mg/8 hour intravenous
(C16.9) : 1 pt Merak D
10. General Peritonitis cb perforated Ceftriaxon 1 gr/24 hour intravenous
appendicitis (K35.2) : 1 pt Metronidazol 250 mg/8 hour intravenous
Paracetamol 250 mg/8 hour orally
NGT and DC application
Laparotomy Appendectomy
ER
11. Squamous cell carcinoma of left Ketorolac 30 mg/8 hour intravenous
inguinal region rT3N0M0 (C53.9) Improving general condition
: 1 pt R4A
NO Diagnosis Plan
12. Malingnant neoplasm of tongue Ketorolac 30 mg/8 hour intravenous
on Chemotherapy (C02.0) : 1 pt Improving general condition
R1B
13. Post Total Thyroidectomy Ca Gluconas 10 mg intravenous
Hypocalsemia (E83.5) : 1 pt CaCO3 orally
ER
Tuesday, 7th November 2017
CASE REPORT (18.10)

Six year-old boy, came to Kariadi Hospital Emergency Department with chief
complain pain on all area of his abdomen.

History of illness :
10 days before admission, the patient complains of abdominal pain in the
umbilicus area, pain is felt continuously, fever (+), nausea (-), vomiting (-), no
problem with urinating and defecating. By the parents, the patient was taken to
Bhayangkara Hospital, treated for 4 days, the condition improved and allowed
to go home.
3 days before admission, the patient complained of abdominal pain again, felt
continuously and moved from the umbilicus area to the lower right abdomen,
fever (+), nausea (-), vomiting (-), no problem with urinating and defecating, the
patient was taken to see a doctor near the house but there has been no
improvement.
1 day before admission, the patient feels continuous pain on the whole
abdomen, nausea (-), vomiting (-), urinating (+), defecation (-). by the parents,
patient was taken to Kariadi Emergency Department.
History of Past Illness :
History of pain in the right lower quadrant of abdomen (-)
History of pain when urinating (-)

Family History of Illness :

History of illness (-)

Socio Economic History :

Patient are financed by JKN
Physical Examination :
General condition : Looks moderate ill
Vital sign
RR = 23 x/mnt
HR = 92 x /mnt
BP = 110 / 70 mmHg
GCS = E4M6V5 =15
t = 38C ( A )
Pain = 3-4 (Wong Baker)

Head : mesosefal, skin turgor wasnt decreased

Eye : anemic conjungtiva (-/-), icteric sklera (-/-)
sunken eyes (-)
Mouth : dry lips (-)
Chest:
Lung :
I : static : right hemithorax = left hemithorax
dynamic : right hemithorax = left hemithorax
Pa : tactile fremitus right = left
Pe : sonor all around area
A : vesicular breath sound, additional sound (-)
Heart:
I : ictus cordis not seen
Pa : ictus cordis palpated 5th ICS, at 2 cm medial midclavicle line
Pe : configuration wnl
A : basic heart sound wnl

Abdomen :
I : flat, bowel movement (-), bowel pattern (-)
Pa : pain on all abdomen with punctum maximum at mc.burney
point, rebound tenderness (+), defans muscular (+)
Pe : tympanic, liver dullness (-), flank dullness (+),
shifting dullness (-), pain on percussion (+)
Au : Bowel sound decreased 10
External genitalia : Male, wnl

D.R.E : Anal sphincter tone was enough, smooth mucous, ampula recti was not
collaps, no tumor/mass, pain on all area
Glove : stool (+), blood (-), mucous (-)

Extremities : Upper Lower

cyanosis -/- -/-
cold acral -/- -/-
deformities -/- -/-
motoric 555/555 555/555
sensoric good good
Working Diagnosis (18.20)
Generalized peritonitis cb hollow viscus perforation cb susp. perforated appendicitis

Initial Management
Ip Dx :
S:-
O: Plain Abdominal Xray 2 position
Ip Tx :
Lactat Ringer 12 drops/minute intravenous
Ceftriaxon 1 gr / 24 hours intravenous
Metronidazole 250 mg / 8 hours intravenous
Inserted DC 8 Fr initial 100 cc yellowish clear urine emptied
NGT application clear fluid
Ip Mx:
Complain, vital sign, laboratorium study, urine production, NGT production
Ip Ex :
diagnosis, examination planning, prognosis
Laboratory Study (19.30)
Hb : 11,7 gr % (10,5 15 gr %)
Ht : 34,7 % (36 44 %)
Leu : 21.200/mmk (5.000 13.500/mmk)
Tromb : 516.000/mmk (150.000 400.000/mmk)
PPT/K : 14.5/10.6 det (11,1 12,4 det)
APTT/K : 48.1/34.6 det (32,3 33,1 det)
GDS : 94 mg/dL (80 160 mg/dL)
Ur : 14 mg/dl (15 39 mg/dl)
Cr : 0,6 mg/dl (0,6 1,3 mg/dl)
Na : 132 mmol/l (136 145 mmol/L)
K : 3,6 mmol/l (3,5 5,1 mmol/L)
Cl : 95 mmol/l (98 107 mmol/L)
Lactat : 2.0 mmol/l (0,4 2,0 mmol/l)

Radiology Kariadi Hospital (19.45)

Plain Abdominal Xray 2 position
Diagnosis (19.50)
Generalized peritonitis cb hollow viscus perforation cb susp. perforated
appendicitis

Management (10.50)
Dx :
S:-
O: -
Tx :
Lactat Ringer 12 drops/minute intravenous
Ceftriaxon 1 gr / 24 hours intravenous
Metronidazole 250 mg / 8 hours intravenous
Laparotomy appendectomy
Mx :
Complain, vital sign, urine production, NGT production
Ex :
diagnosis, prognosis, treatment planning
Operation report (11.00-13.00)
Patient supine position under general anasthesia.
Antiseptic and aseptic operation area.
Performed transversal incission infraumbilical, then deepened it layer by layer
Opened peritoneal cavity, came out yellowish clear fluid
Omentum was seen leading to right lower quadrant, adhesion (+), could not been
moved omentectomy was done.
Explore the appendix : edematous, hiperemic, pus (+) 20 cc on right lower quadrant,
perforation on the edge of the appendix.
Cut the base of appendix, clamp 0,5 cm from base of appendix, suture with the silk
2.0 at the base of appendiks, cut the appendix using scissor between clamps and
ligated suture sent to pathology anatomy
Wash di abdominal cavity with warm normal saline, as clean as possible
Put 1 NGT 14 Fr as a drain on right lower quadrant
Guardix application
Suture the operation wound layer by layer
Operation finished
Post Operation Diagnosis (13.05)
Generalized peritonitis cb perforated appendicitis
Post laparotomy appendectomy

Management post operation (13.10)

Dx :
S:-
O: -
Tx :
Lactat Ringer 12 drops/minute intravenous
Ceftriaxon 1 gr / 24 hours intravenous
Metronidazole 250 mg / 8 hours intravenous
Tramadol 50 mg / 8 hours intravenous
Paracetamol 250 mg / 8 hours peroral
Drain is clamp for next 24 hours

Mx:
Complain, vital sign, GCS, urine production, NGT production, drain production

Ex :
diagnosis, prognosis, treatment planning