Duty Report

Wednesday, February 8th 2017

Consultants on duty :
dr. M. Iqbal Rivai, SpB KBD
dr. Hermansyah, Sp.OT
dr. Syaiful Saanin, SpBS
dr. Yevri Zulfiqar, Sp. B, Sp.U

Residents on duty :
Peri, Fitri, Mirton, Faris, Tondy, Siska, Satria,
Ames, Reza, Niko, Aulia
Total patient : 3 patients
Patient underwent operating : 1 patient
In patient : 1 patient
Out patient : 1 patient
Patient refused to be treated : - patient

Sum of patient in the ward :

TC : 30 patients
HCU : 9 patients
CP : 22 patients
CW : 27 patients
CAA : 10 patients
BU : 5 patients
 Patient
A male baby patient, 1 day old, was admitted to ER with:

Chief Complaint:
Excessive salivation since 1 day before admission
Present Illness History :
• Excessive salivation since 1 day before admission
• Breathlessness since 8 hours before admission
• Patient haven’t had breastfed or given milk since
birth
• History fail to insert feeding tube (+)
• Meconium (+)
• Patient was section caesarean labored because of
postdate and IUGR, second pregnancy, first baby,
birth weight 2100 gr, routine control to midwife.
 Physical Examination
• General appearance : moderately illness
• Consciousness : less active
• HR : 158 x/ minute
• RR : 68 x/ minute
• Temperature : 37OC

Eye : Conjunctive was not anemic

Locally State :

Mouth : Excessive salivation (+)

Thorax region :
I : chest wall retraction (+),
A : vesicular breath sound on right side = left side, with ronchie (+) on the right side
P : ictus cordis on left side

Abdomen Region :
I : Distended (+) at epigastrium
A : Bowel sound (+)

Genital region :
I : Scrotum (+) bifida, micropenis (+), MUE at the tip of the glans
Pal : Testis (+) on right and left scrotum

Anorectal Region :
I : Anus (+)
Clinical picture
Working diagnosed :
Susp. esophageal atresia with aspiration pneumonia

Laboratory findings :
Hb : 16,1 gr%
WBC : 11.710/ mm3
Platelet : 147.000/ mm3
Sodium : 134 mmol/L
Potassium : 3,5 mmol/L
AGD pH 7,15
PCO2 38
PO2 62
HCO3- 13,2
X-Ray
Diagnose :
Esophageal atresia with TEF
Aspiration pneumonia
Patient was prepared at pre – operative room:
• Informed consent
• NPO
• IVFD + rehydration
• Catheter urine
• Antibiotics
• Consult to pediatrician

We plan to performed:
Gastrostomy Emergency
 Rehydration
• D : 2100 gr – 2000 gr = 100 cc
• M : 2kg x 100 cc = 200 cc

• Bolus 20x2=40 cc
• Dehydration = 100-40 = 60cc
1st 6 hours = ½ D + ¼ M
= 30 + 50 = 80 cc
2nd 18 hours = ½ D + ¾ M
= 30 + 150 = 180 cc
 Operative Report
• Supine position under local anesthesia
• Disinfection of the operating field
• Transverse incision at left paramedian supra
umbilicus, open cutis, subcutis, fascia, muscle
splitting, peritoneum
• Identification corpus of gaster
• Performed gastrostomy
• Control bleeding
• Close wound layer by layer
Patient condition this morning :
Patient is in the NICU
S : fever (-), breathlessness (+), defecation (+)
O : intubated, HR : 152 x/minute, RR : 64x/min on CPAP,
Temp. : 37,2OC

Mouth region : Excessive salivation (+)

Thorax region : breathing sound right = left, ronchi (+)/(-)
Abdomen region : wound is good, gastrostomy is good,
distention (-)

Planning : echocardiograpy
 In Patient
A female patient, 54 years old, was admitted to ER with:

Diagnose:
Observation of abdominal blunt trauma with stable
haemodinamic
S39.81XA Other specified injuries of abdomen, initial encounter
Foto klinis
FAST
Condition patient this morning
• Patient is in the ward
• S : abdominal pain (-)
• O : Consiousness : GCS 15
BP : 130/ 70 mmHgT : 37 OC
RR :18x/minute HR : 80 X/minute

Abdominal region
I : distended (-)
Au : bowel sound (+)
Pal : MR (-), tenderness (-), rebound tenderness (-)
 In Patient
A male patient, 31 years old, was admitted to ER with:

Diagnose:
Observation of blunt abdominal trauma with stable
haemodynamic
S39.81XA Other specified injuries of abdomen, initial encounter

Closed fracture of left 5th costae

S22 Fracture of rib(s), sternum and thoracic spine
Clinical picture
FAST
Rontgen
CT Scan
Condition patient this morning
• Patient is in the ward
• S : Consiousness : composmentis
• O : GCS 15
BP : 100/ 70 mmHgT : 37 OC
RR :20x/minute HR : 84 X/minute
Thorax Region:
I : chest movement right = left
Au : vesicular breathing sound right = left
Per : sonor L = R
Pal : crepitation (+) at lateral of left hemithorax with pain
decreased

Abdominal region
I : distended (-)
Au : bowel sound (+)
per : timpany
Pal : MR (-), tenderness (-), rebound tenderness (-)
CT Scan