MORNING REPORT

MONDAY, AUGUST 23rd 2021

Residents on duty :
AGI/MUH– HIL/NUR/ROI - FIF
IZI/ROS/GIR/KEN - GIN/BIM/TOS - RUL
MIR - ISA - HAM

Morning Report and Interdiciplines Group Coordinators:

dr. Muhammad S. Niam, M.Kes, Sp.B-KBD.
dr. Ananto Satya Pradana, SpOT.
dr. Kurnia Penta Seputra, SpU(K).
 ISS : 8
MR. NASRIPAN/M/47 YO/11516206

AFTERNOON
RTS : 7.841
ToAcc : (18/08/2021)
ToArr INCOVID : 10.00 (23/08/2021) PS : 99.46%
ToCT : 12.00 (23/08/2021, Saiful Anwar Hospital)
ToS : 15.00
Time General Status Problem
OPERATIONS Diagnosis Problem Solving / Management
TAL, ASP
Final Diagnosis
10.00 A : Patent Patient was referred from Mitra Pandaan Hospital Mild head injury Head elevation Traumatic SAH
B : Spontaneous with decreasing of consciousness after motorcycle Oxygen supplementation (S06.6)
symmetrical accident 5 days before admission. SAH Fluid administration
RR= 20x/min Pain and wound in R lower leg Analgetics Traumatic Subdural
C : HR= 82x/min, BP : History decreased of conciousness Subdural Hygorme L Tranexamic acid Hygrome
131/62 mmHg fronto-parietal region Human Anti Tetanus (S06.5)
D : GCS 356 Billateral Periorbital hematome Immunoglobulin
isochoric pupils Neglected OF R Proximal Observation for VS, GCS, Probable Covid-19
3mm/3mm Localized state : shaft tibia fibula gr II vomiting, seizures and (U07.1)
R lower leg : lateralization
MOI : Motorcycle L : Open wound, size 6 x 2 cm bone based on Neglected OF R calcaneus Swab PCR Neglected OF R Proximal
accident medial side, size 7 x 2 cm muscle based on posterior shaft tibia fibula gr II
side, size 5 X 3 cm muscle based on lateral side Open wound posterior and
F : Tenderness (+), NV distal normal lateral side R Lower leg Neurosurgery Department : Neglected OF R calcaneus
Pulsation of dorsalis pedis & tibialis posterior artery - Planning for Head CT
Traveling history (+) (+) Pneumonia atypical ec Evaluation GCS still 356 or Open wound posterior and
Contact history with M : ROM limited susp probable covid – 19 decrease > 2 point lateral side R Lower leg
COVID patient (-) Knee flexion -extention : 0-5° infection - Planning for burrhole drainage
Red zone area (+) Ankle plantar & dorsoflexion : 0-5° if hygrome increase
Saturation all toes: 94-100%
Orthopaedic Department :
Today condition: Laboratory result : R lower leg & Ankle
GCS : 456 Hb : 9.3 - Debridement + external fiksasi
Isocoric pupil Leucocyte : 8.640 - Backslab
3mm/3mm Abs neutrophil : 6.540 - ORIF planned
Abs lymphocyte : 820
NLR : 7.89
Swab antigen : negative Join care with Pulmonology
Department
 ISS : 8
MR. NASRIPAN/M/47 YO/11516206

AFTERNOON
RTS : 7.841
ToAcc : (18/08/2021)
ToArr INCOVID : 10.00 (23/08/2021) PS : 99.46%
ToCT : 12.00 (23/08/2021, Saiful Anwar Hospital)
ToS : 15.00
Time General Status Problem
OPERATIONS Diagnosis Problem Solving / Management
TAL, ASP
Final Diagnosis
R Lower leg X-ray : Mild head injury Head elevation Traumatic SAH
Fracture proximal shaft tibia & fibula Oxygen supplementation (S06.6)
  SAH Fluid administration
Head CT without contrast (Saiful Anwar Analgetics Traumatic Subdural
Hospital, 23/8/2021) Subdural Hygorme L Tranexamic acid Hygrome
-Subdural Hygrome L fronto-parietal lregion (thick fronto-parietal region Human Anti Tetanus (S06.5)
5 mm) Immunoglobulin
-SAH Neglected OF R Proximal Observation for VS, GCS, Probable Covid-19
shaft tibia fibula gr II vomiting, seizures and (U07.1)
lateralization
Neglected OF R calcaneus Swab PCR Neglected OF R Proximal
shaft tibia fibula gr II
Open wound posterior and
lateral side R Lower leg Neurosurgery Department : Neglected OF R calcaneus
- Planning for Head CT
Pneumonia atypical ec Evaluation GCS still 356 or Open wound posterior and
susp probable covid – 19 decrease > 2 point lateral side R Lower leg
infection - Planning for burrhole drainage
if hygrome increase

Orthopaedic Department :
R lower leg & Ankle
- Debridement + external fiksasi
- Backslab
- ORIF planned

Join care with Pulmonology

Department
MR. NASRIPAN/M/47 YO

Billateral Periorbital hematome

MR. NASRIPAN/M/47 YO
MR. NASRIPAN/M/47 YO

Subdural Hygrome L fronto-parietal

SAH
region
MR. NASRIPAN/M/47 YO

Head CT-Scan Saiful Anwar Hospital

23/08/2021
MR. SONNY ARIEF/M/52YO/11516275
ToArr
ToS
: 18.00
: 23.00 EVENING HER,
Nursamsu
OPERATIONS
Time General Status Problem Diagnosis Problem Solving / Management Final Diagnosis
18.00 RR : 19 x/min Unrreducible mass and pain in R Working Dx : Oxygen Supplementation Unilateral or unspecified
BP : 130/80 mmHg inguinal region for 3 day. Incarcerated R inguinal Fluid administration inguinal hernia, with
HR : 76 x/min Vomiting. hernia Analgetics obstruction, with gangrene
Tax : 36,3°C History of reducible mass 1 year Antibiotics (K40.3)
before admission. Primary Dx : NGT Insertion
History of HbsAg (+) Incarcerated R inguinal Urethral catheterization Acute Kidney Injury
hernia Obs for VS and sign of acute (N17)
History of traveling to Abdominal distension, decreasing of abdomen
redzone (-) bowel sound Secondary Dx : Hepatitis B Infection
History of contact with Mass in R scrotal region, sized - AKI (B18.1)
COVID-19 patient (-) 4x3x4cm. - Chronic hepatitis B
DRE : infection Hyponatremia
Anal sphincter tonus (+), Collapse of Exploratory Laparotomy (E87.1)
rectal ampula, stool (-), mass (-). Complication Dx : (54.11)
Hyponatremia
Laboratory Results : Repair of Hernia
SE : 121/3,21/83 (53.0)
CRP : 43,28
Procalcitonin : 8,19 Resectiojn of Intestine
Abs Lymphocyte : 0,61 (45.6)
Abs Neutrophile : 7,92
NLR : 12,96 Ileostomy
Albumin : 2,56 (46.2)
COVID Antigen swab : Negative

Chest X-Ray : Join care with Internal Medicine

Within normal limit Department
 MR. SONNY ARIEF/M/52YO

Mass in R scrotal region, sized

4x3x4cm
MR. SONNY ARIEF/M/52YO
 MR. SONNY ARIEF/M/52YO
Durante Operation

Unviable intestine Entrapment Segment of intestine

BB. MUH ILHAM/M/1YO/7,5KG/11494163
ToArr : 01.05 (24/8/2021)
ToCT : 02.00 (24/8/2021)
To Adm : 04.00 EVENING TAL, Saptadi

Time General Status

01.05 HR = 140 x/min

Problem

Restless and has difficulty to sleep.

ADMISSIONS Diagnosis

Working dx:
Problem Solving /
Management
Head elevation
Final Diagnosis

Arachnoid cyst
RR = 46 x/min Vomiting 3 times Obs Vomiting Oxygen supplementation (G96.19)
pGCS = 456 History of VP shunt R Keen ( in RSSA October Fluid administration
isochoric pupil 2020) and VP shunt moderate pressure burrhole L Primary dx: Observation for VS, GCS, Malfunction VP shunt
3mm/3mm Keen RSSA at 13 April 2021 Intraventricullar vomiting, seizures and (T85.09)
History of moderate secundum ASD, moderate multiloculated arachnoid lateralization
No Lateralization VSD, moderate pulmonary hypertension cyst with malfunction Septo-optic dysplasia of brain
History of routine medication with Sidenafil, shunt (Q04.4)
Captopril and KSR
History of traveling to   Secondary dx: Plan for : Atrial Septal Defect
redzone (-) Scar post op VP shunt R keen and L kocher - Agenesis of septum - Endoscopic Cyst (Q21.1)
History of contact with Head circumference : 48 cm pellucidum Fenestration
COVID-19 patient (-) - Moderate ASD - Endoscopic Third Ventricular Septal Defect
Laboratory result : secundum L-R shunt Ventriculostomy (Q21.0)
Leucocyte : 12.770 - Moderate VSD PMO L- - VP shunt R kocher point
Absolute Neutrophyle : 5,83 R shunt with low pressure Pumonary hypertension
Absolute Lymphocyte : 6,1 - Aff R keen point VP (I27.20)
NLR : 1,01 Complication dx: shunt
D-Dimer : 16,98 - Hydrocephalus Hydrocephalus
Swab Antigen : negative - Mild PR (G91.9)
- Moderate pulmonary
Today’s Condition Head CT Scan RSSA 13/05/2021 : hypertension
GCS 456 Hydrocephalus communicans
Isochoric pupil Tip VP shunt in R ventrikel lateral Join care with Pediatric
3mm/3mm Department
BB. MUH ILHAM/M/1YO/7,5KG/11494163
ToArr : 01.05 (24/8/2021)
ToCT : 02.00 (24/8/2021)
To Adm : 04.00 EVENING TAL, Saptadi

Time General Status Problem

Head MRI with contrast RSSA 3/6/2021

ADMISSIONS Diagnosis

Working dx:
Problem Solving /
Management
Head elevation
Final Diagnosis

Arachnoid cyst
Multiloculated cystic lesions on intraventricular III Obs Vomiting Oxygen supplementation (G96.19)
and IV suspected intraventricular arachnoid cyst Fluid administration
causing severe obstructive hydrocephalus as high as Primary dx: Observation for VS, GCS, Malfunction VP shunt
ventricular level III on VP shunt --> relatively fixed Intraventricullar vomiting, seizures and (T85.09)
mass size, relatively fixed hydrocephalus. multiloculated arachnoid lateralization
- agenesis of the septum pellucidum, dysgenesis of cyst with malfunction Septo-optic dysplasia of brain
the corpus callosum shunt (Q04.4)

Head CT RSSA 24/8/2021 Secondary dx: Plan for : Atrial Septal Defect
- Multiloculated cystic lesions on intraventricular III - Agenesis of septum - Endoscopic Cyst (Q21.1)
and IV suspected arachnoid cysts causing severe pellucidum Fenestration
obstructive hydrocephalus at the level of the third - Moderate ASD secundum - Endoscopic Third Ventricular Septal Defect
ventricle in VP shunts, the degree of hydrocephalus L-R shunt Ventriculostomy (Q21.0)
increased, the size of the lesions was relatively - Moderate VSD PMO L-R - VP shunt R kocher point
constant. shunt with low pressure Pumonary hypertension
- Agenesis of the septum pellucidum, dysgenesis of - Aff R keen point VP shunt (I27.20)
the corpus callosum. Complication dx:
- Hydrocephalus Hydrocephalus
Echocardiograhy (17/05/21) - Mild PR (G91.9)
- Moderate ASD secundum L-R shunt - Moderate pulmonary
- Moderate VSD PMO L-R shunt hypertension
- Mild PR Join care with Pediatric
- Moderate TR Department
- Moderate pulmonary hypertension
- decrease systolic function RV
BB. MUH ILHAM/M/1YO
 BB. MUH ILHAM/M/1YO

Hose of R VP
Shunt Hose of R VP
Shunt

CHEST XRAY SAIFUL ANWAR HOSPITAL 24/8/21

BB. MUH ILHAM/M/1YO

HEAD CT SAIFUL ANWAR HOSPITAL 13/5/21

BB. MUH ILHAM/M/1YO

Hydrocephalus communicans

HEAD CT SAIFUL ANWAR HOSPITAL 13/5/21

BB. MUH ILHAM/M/1YO

HEAD MRI SAIFUL ANWAR HOSPITAL 3/6/21

BB. MUH ILHAM/M/1YO

HEAD MRI SAIFUL ANWAR HOSPITAL 3/6/21

BB. MUH ILHAM/M/1YO

HEAD MRI SAIFUL ANWAR HOSPITAL 3/6/21

BB. MUH ILHAM/M/1YO

Multiloculated cystic lesion on

intraventrikel III & IV

HEAD MRI SAIFUL ANWAR HOSPITAL 3/6/21

BB. MUH ILHAM/M/1YO

HEAD CT SAIFUL ANWAR HOSPITAL 24/8/21

 BB. MUH ILHAM/M/1YO

Tip of R VP Shunt

Tip of L VP Shunt

HEAD CT SAIFUL ANWAR HOSPITAL 24/8/21

BB. MUH ILHAM/M/1YO

ECHOCARDIOOGRAPHY SAIFUL ANWAR HOSPITAL 17/5/21

BB. MUH ILHAM/M/1YO

ECHOCARDIOOGRAPHY SAIFUL ANWAR HOSPITAL 17/5/21

MRS.CHOLIFAH/F/55YO/11516262
ToArr : 14.00
ToAdm : 16.00

Time General Status

AFTERNOON ADMISSIONS
Problem Diagnosis Problem Solving /
HER
Final Diagnosis
Management
14.00 RR = 20 x/min Yellowish body and eye for 2 weeks Working Dx : Oxygen Cholangitis
BP = 130/82 mmHg Intermittent abdominal pain in right upper Moderate cholangitis supplementations (K83.0)
HR = 96x/min quadran for 3 week Fluid administration
T = 36,5°C History of fever for 2 weeks Primary Dx : Analgetics Choledocolithiasis
GCS : 456 History of pale yellow stools and yellow Moderate Cholangitis dt Antibiotics (K80.50)
VAS : 3/10 concentrated urine for 2 weeks colelithiasis dd susp Vit K
Choledocolithiasis Tranexamic acid Anemia
Sclera icteric Observation for VS, (D63.0)
murphy’s sign (+) Secondary Dx : signs of acute
Acute cholecystitis abdomen Jaundice
Traveling history (+) Laboratory Results Improve general (R17)
Contact history with Hb : 9.4 Complication : condition
COVID patient (-) Leucocyte : 13.060 Anemia
Red zone area (+) Abs. neutrophille : 10.360 Jaundice Transfusion of packed
Abs lymphocyte : 1.980 Hypoalbuminemia cell
NLR : 5.23 (99.04)
Bil. T/D/I : 11.2/8.37/2.83
Alb : 3.12 Transfusion of serum
Antigen sars cov-2 : negative plasma
(99.05)
Chest X-Ray
Within normal limit Plan for urgent MRCP
(88.97)
Abdominal US (Wonolangan Hospital,
18/8/2021) Plan for PTBD
- Multiple cholelithiasis with diameter 0.7 cm to (51.9)
1.2 cm with thickening wall of gallbladder
- Dilatation of proximal CBD and IHBD
MRS.CHOLIFAH/F/55YO

Chest X-Ray (18/8/2021

Wonolangan Hospital)
MRS.CHOLIFAH/F/55YO

Abdominal US (18/8/2021
Wonolangan Hospital)
MRS.CHOLIFAH/F/55YO

Multiple stone in gallbladder with thickening

Abdominal US (18/8/2021 wall of gallbladder
Wonolangan Hospital)
MR. SOLIKIN/M/58YO/11516270 ISS : 11
ToAcc : 09.00 RTS : 7.8408
ToArr : 14.30
ToCT : 15.00 EVENING OPERATIONS PS : 98.90%
TAL, BP, ASP
ToS : 23.00
Time General Status Problem Diagnosis Problem Solving / Management Final Diagnosis

14.30 A : Patent Headache Mild Head Injury Oxygenation Concussion

B : spontaneous symmetrical
RR = 20 x/min
C : BP = 130/80 mmHg
HR = 90 x/min
D : GCS = 456
isochoric pupils
3mm/3mm
Travelling History (-)
Contact history with COVID
patient (-)
Red zone area (+)
Lawang, Malang
MOI : Single Motorcycle
accident
Today’s condition :
GCS 456
isochoric pupils
3mm/3mm
Pain in face and hand after motorcycle Head elevation (S06.0)
accident Multiple abrasions of face Fluid administration
Analgetics Abrasion of face
L hand : CF L 1st base metacarpal Human Anti Tetanus (S00.81)
L : Swelling, open wound at dorsal side intraarticular immunoglobulin
ring finger size 3.5 x 2.5 cm, tendon Observation for VS, GCS, CF L 1st base metacarpal
intact, bone based CF L 2nd base metacarpal vomiting, seizures intraarticular
F : Tenderness, NV distal normal Facial abrasion wound care with (AO70D2.1 IC1 MT1 NV1)
M : ROM limited OF L 4th & 5th neck hydrocolloid
MCP, PIP, DIP flexion - extension : 0-5° metacarpal CF L 2nd base metacarpal
Neurosurgery Department : (AO70D1.2 IC1 MT1 NV1)
R & L knee : CF L capitatum non Non Operative Management
L : abrasion (+), anterior side displaced OF L 4th & 5th neck
F : tenderness (+), NV distal normal Plastic Surgery Department : metacarpal
M : ROM normal CF L Trapezoid minimal Debridement (AO70D1.4-5 IO1 MT1 NV1)
displaced (86.22)
Laboratory Results CF L capitatum non displaced
Absolute Neutrophyl : 4,09 Vulnus abration anterior Orthopaedic Department :
Absolute Lymphocyte : 1,64 side knee bilateral L hand : CF L Trapezoid minimal
NLR : 2,49 -Debridement displaced
Swab Antigen : -K-wire fixation
-Splint Vulnus abration anterior side
Chest-Xray : Knee : knee bilateral
Within normal limit -Wound care (MT1 NV1)
MR. SOLIKIN/M/58YO/11516270 ISS : 11
ToAcc : 09.00 RTS : 7.8408
ToArr : 14.30
ToCT : 15.00 EVENING OPERATIONS PS : 98.90%
TAL, BP, ASP
ToS : 23.00
Time General Status Problem Diagnosis Problem Solving / Management Final Diagnosis

Hand X-Ray AP/Lateral : Mild Head Injury Oxygenation Concussion

- Fracture line at trapezoid,
capitatum, base 1st metacarpal
intraarticular, at base 2nd
metacarpal, neck 4th & 5th
metacarpal, at shaft proximal
phalanx ring finger
Head CT-Scan :
No intracranial haemorhhage
Head elevation
Multiple abrasions of face Fluid administration
Analgetics
CF L 1st base metacarpal Human Anti Tetanus
intraarticular immunoglobulin
Observation for VS, GCS,
CF L 2nd base metacarpal vomiting, seizures
Facial abrasion wound care with
OF L 4th & 5th neck hydrocolloid
metacarpal
Neurosurgery Department :
CF L capitatum non Non Operative Management
displaced
Plastic Surgery Department :
CF L Trapezoid minimal Debridement
displaced (86.22)
Vulnus abration anterior Orthopaedic Department :
side knee bilateral L hand :
-Debridement
-K-wire fixation
-Splint
Knee :
-Wound care
(S06.0)
Abrasion of face
(S00.81)
CF L 1st base metacarpal
intraarticular
(AO70D2.1 IC1 MT1 NV1)
CF L 2nd base metacarpal
(AO70D1.2 IC1 MT1 NV1)
OF L 4th & 5th neck
metacarpal
(AO70D1.4-5 IO1 MT1 NV1)
CF L capitatum non displaced
CF L Trapezoid minimal
displaced
Vulnus abration anterior side
knee bilateral
(MT1 NV1)
MR. SOLIKIN/M/58YO

Multiple abrasion wound of

Face
MR. SOLIKIN/M/58YO
MR. SOLIKIN/M/58YO
MR. SOLIKIN/M/58YO
 MR. SOLIKIN/M/58YO
Site: 1st, 2nd, 4th & 5th metacarpal
Extent: Complete fracture
Configuration : oblique
Relationship of the fracture
fragment to each other:
displaced

Angulation
1st metacarpal
AP : 2°
Lat : 5°

2nd metacarpal
AP : 2°
Lat : 5°

4th metacarpal
AP : 2°
Lat : 20°

5th metacarpal
AP : 10°
Lat : 25°
MR. SOLIKIN/M/58YO
MR. SOLIKIN/M/58YO

Chest XRay Saiful Anwar Hospital

23/08/2021
MR. SOLIKIN/M/58YO

Head CT-Scan Saiful Anwar Hospital

23/08/2021
MR. SOLIKIN/M/58YO

Head CT-Scan Saiful Anwar Hospital

23/08/2021
MR. SOLIKIN/M/58YO
PRE OPERATION

Multiple abrasion wound of

Pre Op
Face
MR. SOLIKIN/M/58YO
POST OPERATION

Multiple abrasion wound of

Post Op
Face
MR. SOLIKIN/M/58YO

DURANTE OPERATION
MR. SOLIKIN/M/58YO

POST OPERATION
MR. SOLIKIN/M/58YO
MR. PURWANTO/M/70YO/11516274 ISS : 4
ToAcc : 13.40 RTS : 7.8408
ToArr : 15.00
ToS : 18.00
AFTERNOON PS : 98.90%

SUS
Time

15.00
General Status

A : Patent
Problem

Pain and open wound wound in back

OPERATIONS Diagnosis

Open wound L thorax

Problem Solving / Management

Oxygenation
Final Diagnosis

Open wound of back wall of

B : spontaneous Pain and abrasion wound on the L forearm Posterior region Head elevation thorax
symmetrical Localized St. L Thorax Posterior Fluid administration (S21.2)
RR= 20x/min Open wound sized 10 x 6 cm muscle based. Open wound flexor zone V R Analgetics
C: Forearm with total rupture Human Anti Tetanus Immunoglobulin Open wound flexor zone V R
BP=134/78 mmHg R Forearm : FCR tendon Observation for VS Forearm with total rupture FCR
HR=86x/min L : Open wound (+), volar side, size 4x1cm, tendon tendon
D: based Multiple vulnus abrasion Cardiothoracic Surgery (MT4 NV1)
GCS=456 F : Tenderness (+), NV distal normal dorsal side L forearm Department :
isochoric pupils M : ROM normal Excisional Debridement Multiple vulnus abrasion dorsal
3mm/3mm Wrist flexion : 0-80◦ Hipertension st I uncontrolled (86.22) side L forearm
Wrist extension : 0-75◦ (MT1 NV1)
MOI : Fallen and Primary closure
while walking Saturation of all finger : 98-99% (34.82) Hipertension
backwards and hit the (I100
broken glass L Forearm : Orthopaedic Department :
L : Multiple vulnus abration (+), dorsal side, size 1x1 R Forearm :
cm, 2x1cm, 2x1 cm -Debridement
Traveling history (+) F : Tenderness (+), NV distal normal -Explore
Contact history with M : ROM normal -Repair
COVID patient (-) -Splint
Red zone area (+) Laboratory Results
Leucocyte : 6.050 L Forearm:
Absolute Neutrophyl : 4,09 -Wound care
Absolute Lymphocyte : 1,64
Today’s condition : NLR : 2,49
GCS 456 Antigen SARS Cov-2 : Negative
isochoric pupils
3mm/3mm Chest-Xray : Join care with Internal Medicine
within normal limit Department
MR. PURWANTO/M/70YO
MR. PURWANTO/M/70YO

Open wound
MR. PURWANTO/M/70YO
MR. PURWANTO/M/70YO
MR. PURWANTO/M/70YO

Chest X-Ray
MR. PURWANTO/M/70YO

Pre Op
MR. PURWANTO/M/70YO

Post Op
MR. PURWANTO/M/70YO
MR. PURWANTO/M/70YO

Total rupture FCR tendon

MR. PURWANTO/M/70YO

Intact FPL tendon

MR. PURWANTO/M/70YO

Post repair FCR tendon

MR. PURWANTO/M/70YO
MR. PURWANTO/M/70YO
 OUTPATIENTS
N
NAME DIAGNOSIS COMMENTS
O
Malignant neoplasm of breast T4bN1M1 (Spine,
1. Mrs.Lailatul Badriyah/F/57YO/11516235 Contralateral, Lung) on chemotherapy CEF 6 x + Discharged
Zoladex 4x + Pleural Effusion + Post Thoracocentesis
2. Ms. Maria Angelina/F/18YO/11516280 Open wound L pinna regiion dt ear ring entrapment Discharged
Intraabdominal tumor susp malignancy + anemia +
3. Mrs. Astopa/F/61YO/11516277 Refused Admissions
pneumonia susp covid-19 infection critically ill
THANK YOU
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