Tuesday, December 4th 2018

MSH/WHY/VAN/CAR/WHS/SAP/HMP/VAL
In emergency installation we receive …. patient consist of:
No Diagnosis Plan
1 Excoriation wound (T14.0) Debridement
Amoxicillin 500mg / 8 hours orally
 2 Patients Mefenamic acid 500mg / 8 hours
orally

 Discharged
2 Mild head injury GCS E3M6V5 = Oxygenation
14, Head up 300
Thoracoabdominal blunt trauma Observation
with stable HD X-ray cervical AP
cb. Traffic accident 30 minutes X-ray thorax AP/Lat
before admission MSCT abdomen with contras

 1 Patient  Discharged
No Diagnosis Plan
3 Closed fracture of right lower leg Splint application
cb. Cement grinder machine Ketorolac 30 mg / 8 hours intravenous
Ranitidine 50 mg / 12 hours
 1 Patient intravenous
X-ray right cruris AP/Lat

4 Suspect closed fracture of left
lower arm,
Suspect closed fracture of right
lower leg
Cb. Traffic accident 30 minutes
before admission
 KPD DASAR
Splint application
X-ray left antebrachii AP/Lat
X-ray right cruris AP/Lat
Refused for further treatment

 1 Patient
No Diagnosis Plan
5 Adenocarsinoma rektosigmoid Ketorolac 30 mg / 8 hours intravenous
T4N1M1 (hepar) with
impending obstruction
 R4B

 1 Patient
6 Cronic appendicitis, Appendectomy elective
PDA Join management with Cardio
department
 1 Patient
 ER
7 Obstructive jaundice with anemia Ketorolac 30 mg / 8 hours intravena
Vitamin K
 1 Patient
 ER
No Diagnosis Plan
8 Fistule enterocutan post Debridement
appendectomy (11/11/2018) Stoma bag application
 1 Patient Join management with Pediatric
department
 C1LD
9 Partial obstruction dd Atresia Oxygenation
duodenum, Keep warm
Severe malnutrition Join management with Pediatric
 1 Patient department
 PBRT
10 Rhabdomyosarcoma on right neck Oxygenation
region with impending airway MST 10 mg / 8 hours orally
obstruction
Prednisone 25 mg / 24 hours orally
 1 Patient
 GRD 1
No Diagnosis Plan
11 Abdominal pain cb. Left kidney Ketorolac 30 mg / 8 hours intravenous
tumor Ranitidin 50 mg / 12 hours
intravenous
 1 Patient
 GRD 1
 Tuesday, December 4th 2018
MSH/WHY/VAN/CAR/WHS/SAP/HMP/VAL
CASE REPORT (20.30)
A 21 year old female came with a chief complaint of right lower
abdominal pain

Chief Complaint : Pain on right lower abdominal

History of current illness:

+ 4 month before admission the patient experienced general
abdominal discomfort with nausea, vomitus, fever (-). Complaint
missing out.
+ 1 month before admission the pain became more prominent on his
lower right abdomen. He experienced fever, and loss of appetite. The
pain was exacerbated with movements, abdominal palpation, and
coughing. He reports no problem in urination.
His parents brought him to internist, given an antibiotics and several
medicine.
+ 1 days before admission the patient felt no improvement, his parents
brought him back to internist, said that he sufferred appendicitis and
then referred to Kariadi Hospital
Physical examination :
General Condition : moderately ill
Vital sign :
RR : 22 times per minutes, regular, enough in depth
PR : 94 times per minutes, regular tone
BP : 110/70mmhg
GCS : E4M6V5=15
Temp. : 37,2 ºC
Pain : 3 - 4 VAS

Head/neck
Conj.palp was not anemic
Dry lips (-)
Normal skin turgor
Chest :
Heart : I : IC was not seen
P : IC was palpable at 5th ICS, 2 cm medial to
Mid Clavicle Line
P : Configuration within normal limits
A : Normal S1 and S2, no murmur, no gallop ryhtim

Lung : I : Static : Right hemithorax = Left hemithorax

Dynamic : Right hemithorax = Left hemithorax
P : Tactile fremitus was equal on both side
P : Sonor on all area
A : Basic sound was vesicular, no additional sound
Abdomen :
I : Flat, no visible bowel pattern / movement.
P : Tenderness on lower right abdominal region,
rigidity (-), rebound tenderness (+), Rovsing’s sign (+).
P : Tympanic, liver Dullness (-) , Flank Dulness (+), Shifting
Dullness (-)
A : Bowel sound (+)

D.R.E : Adequate anal sphincter tone, smooth rectal mucosa, no

mass/tumor palpated, rectal ampulla was not collapsed,
tenderness (-)
Glove : stool (+), mucous (-), blood (-)

External genitalia: female, within normal limits

Extremities : Upper Lower
Cyanosis -/- -/-
Cold extremities -/- -/-
Cap refill <2”/<2” <2”/<2”

13
• Working Diagnosis (21.15):
- Abdominal pain susp appendicitis
Initial Management (21.20) :
Ip Dx :
S :-
O : Abdominal USG, Routine blood examination, diff count.

Ip Tx :
– Inf RL 20 dpm
– Ceftriaxone injection 1gr/ 12 hour intravenous
– Ketorolac injection 30 mg/12 hrs intravenous

Ip Mx :
– Complaint, general condition, vital sign, ureum, creatinine,
electrolite, coagulation study

Ip Ex :
– Informed consent : Diagnostic, surgical treatment, prognosis.
Laboratory study (…….)

• Hb : 19.6 gr% (11,7-15,5)

• Ht : 61.2 %
• L : 10.600/mmk (4000-11000)
• T : 215.000/mmk (150000-450000)
• Ureum : 32 mg/dl (15-40)
• Creatinin : 0.8 mg/dl (0,5-1,3)
• Na : 139 mmol/L (135-145)
• K : 4,6 mmol/L (3,5-5,5)
• Cl : 108 mmol/L (96-106)
• PPT : 15.7/13.6 seconds
• APTT : 47.8/32.3 seconds
• Diff count :
- Eosinofil 3 %, basofil 0 %, batang 2 %, segmen 69 %,
limfosit 20 %, monosit 5 %

USG Appendix RSDK (05-06-18)

 Alvarado Score :
• Migration of pain :
• Anorexia :
• Nausea / vomiting :
• Right lower quadran tenderness :
• Rebound tenderness :
• Elevated temperature :
• Leukocytosis :
• Left shift in leucocyte count :
Total :
Diagnosis (01.30):
Acute exacerbation of Chronic Appendicitis

Management:
Dx:
S :-
O :-
Tx : Pro laparoscopic appendectomy
Mx : General condition, Vital signs
Ex : Diagnosis, operation procedure, complication,
prognosis
OPERATION REPORT (15.00-18.00)
1. Patient in supine position under general anesthesia.
2. Asepsis and antisepsis, narrowed with sterile clothes.
3. Performed infraumbilical semilunar incision + 1,5 cm.
4. Insert trochar no. 10 into the peritoneal cavity, inflate the peritoneum with CO2.
5. Perform incision on suprapubic and left lumbar, insert trochar no. 5
6. Identification of complex adhesions of the right upperabdominal region, complex
adhesion  Performed adhesiolysis,
7. Identification of appendix infiltrate  released from the omentum
8. Cut the mesoappendix with Harmonic scapel, then tied the base of appendix with
endoloop (Polydioxanone) PDS 0 on 2 places, and cut appendix  the appendix
size was + 3 cm in length and 0.8 cm in diameter
9. Identified caecum and ileum within normal limits.
10. Insert endobag into peritoneal cavity, put the appendix into endobag
11. Extract the endobag along with the trochar
12. Wash abdominal cavity with warm normal saline as clean as possible
13. Insert intraperitoneal drain, suture operation wound layer by layer
14. Operation finished
Post op diagnosed (18.15) :
Appendicitis Infiltrate
 Post laparoscopy appendectomy
Post operative management (18.30)
• Diagnosis :
– S: -
– O: -
• Therapy :
– IVFD RL 20 dpm
– Ceftriaxone injection 1 gr/ 12 hrs intravenous
– Metronidazole injection 480 mg/8 hrs intravenous
– Ketorolac 30 mg / 8 hrs intravenous
Monitoring : General condition, vital signs, Operation
wound, drain production
• Education : Diagnosis, operation finding, prognosis
 Follow Up D + 1
S : pain on operation wound (+)
O : general condition : moderately ill
consciousness : composmentis
RR : 18 x/mnt (regular, adequate depth of breath)
HR : 76 x/mnt (regular, adequate tone and volume)
t : 37,0 C
Abdomen :
I : flat, operation wound closed by gauze, imbibition (-)
Pa : supple,
Pe : tymphanic
Au : bowel sound (+) normal

A : stable improvement
P : RL Infusion 20 dpm
– Ceftriaxone injection 1 gr/ 12 hrs intravenous
– Metronidazole injection 480mg/8 hrs intravenous
– Tramadol 100 mg / 8 hrs intravenous
– Ketorolac 30 mg / 8 hrs intravenous
 Tuesday, December 4th 2018
MSH/WHY/VAN/CAR/WHS/SAP/HMP/VAL