2. In Emergency Installation we receive patient, consist of
NO Diagnose Plan
1. Laseration wound
(Ny. Flora S. Widyani, Tn. Setyo
Nugroho, Tn. Hartono,
An.Prasetyo, Tn. Solekan,
An. Zacky Bilal Ramadhan,
Ny.Siti Sunarni)
7 Patients
Wound toilet
Suturing wound
Amoxicilin tab 500 mg/ 8 hours
orally
Mefenamic acid tab 500 mg/ 8 hours
orally
3. No Diagnose Plan
Fracture of zygomaticomaxilary
complex comminutive
Fracture of right ramus of
mandibule
Fracture depressed of right
temporal bone > 1 tabula
Uncomplicated Closed fracture
of left clavicle 1/3 middle
transverse displaced
Fractur of posterior part of 1st left
costa
Subarachnoid hemorrage
c.b accident 12 days before
admission
Oxigenation with 3 Lpm Nasal Canule
Head Up 300
Observation
NGT application
Ketorolac injection 30 mg/ 8 hours
intravenous
Ranitidine injection 50 mg/ 12 hours
intravenous
Liquid diet
Keep oral hygiene
Antiseptic gurgle three time a day
Figure of eight application
Barel fixation application
Facial Bone Reconstruction Elective
Skull Elevation Elektive
ORIF Clavicle Elective
4. No Diagnose Plan
Mandible fracture c.b.traffic
accident 7 days before
admission
(Tn. Suhardilah Dewan)
NGT apllication
Ketorolac injection 30 mg/ 8 hours
intravenous
MSCT facial 3D
Liquid diet
Keep oral hygiene
Barrel fixation application
5. No Diagnose Plan
Uncomplicated Closed Fracture
of right clavicle 1/3 lateral
oblique displaced
Fracture posterior side of 3rd
and 7th of right costa
Fracture of Right Medial
condylus femur
Closed Fracture of right tibial
plateau (Schatzker type VI)
c.b traffic collision
(Tn. Ahmad Sukamdi)
Splint appliccation
Figure of eight application
Ketorolac injection 30 mg/ 8 hours
intravenous
X-ray right knee AP/Lat
X-ray thorax AP
6. No Diagnose Plan
Suspected congenital megacolon
short segmen
(By. Nazril Iqbal Hanafi)
Keep warmth
Washout 1 times daily
Colon in loop
Join Management with Pediatric
Departement
7. No Diagnose Plan
Anorectal malformation with
rectovesica fistula
Undecencus of left Testicle
(By. Ny. Lusia Marantika)
Keep warmth
Maintain OGT application
Maintain urethral catheter application
Colostomy Cito
8. No Diagnose Plan
Tongue tumor suspect
Malignancy T2N2Mx
Severe Malnutrition
(Tn. Adi Oktavianto)
NGT application
Liquid diet
Neck USG
X-ray thorax PA
MST 10 mg/ 12 hours orally
Join management with clinical
nutritionist
9. No Diagnose Plan
Papillary Thyroid carcinoma Post
total thyroidectomy (December
2012)
Post Adenektomi (July2019)
Anemia
(Ny. Rusmi)
PRC Transfusion
MST tab 10 mg/ 12 hours orally
10. No Diagnose Plan
Moderately differentiated
hepatoceluller carcinoma
Post laparoscopy
cholecystectomy + hepar
biopsy ( August 8th 2019)
Anemia
(Tn. Didik Supriyanto)
PRC Transfusion
Omeprazole injection 40 mg/ 12 hours
intravenous
11. No Diagnose Plan
Retensio urine c.b Benign Prostat
Hyperplasia
(Tn. Siswandi)
Urethtral catheter application
12. No Diagnose Plan
Adenocarsinoma of vesica
urinary
History of bilateral nefphrostomi
(July 2019 c.b bilateral
hydronephrosis)
History of chemotherapy 12x
Severe Anemia
(Tn. Ngatomo)
PRC transfusion
15. CASE REPORT (17.38 WIB)
13 days old baby boy was referred from Mitra Keluarga Hospital to
Emergency Department Kariadi Hospital with Imperforate Anus.
Chief Complaint Imperforate Anus
History of Ilness
A baby boy was born from G2 P1A0, 12 days before admission SC
delivery caused by frank breech on the 41 week of pregnancy. Baby was
vigorous, with BW 4100 gram, BL : 48 cm. From physical examination
at Mitra Keluarga Hospital found and told to the family that the baby has
imperforate anus. Urin was unclear. The color is greenish to black.
Because limitation of facilities the baby was referred to Kariadi
Hospital
Antenatal History
No history of infection, no medication, no other family member of
similar condition
16. Physical examination : (17.50 WIB)
General Condition : moderate ill
Vital sign :
RR : 36 times per minutes, regular
HR : 136 times per minutes, regular tone
PGCS : E4M5V6=15
T : 36,8 ºC (A)
Head/neck
Eye : Sunken eyes +/+
Conj.palp was not pale
Sclera was not ikterik
equal round pupil diameter 3 mm, LC (+)(+)
Hypertelorism (+)
Nose : Saddle nose (+)
Ear : Microtia (-) Low set ear
Mouth : Dry lips (+), Cleft (-), hypersalivation (-), cyanosis (-)
Trachea : Deviation (-)
17. Chest :
Heart : I : IC was not seen
P : IC was palpable at 5th ICS, 2 cm medial to
Mid Clavicle Line
P : Configuration w.n.l
A : Pure heart sound, no murmur
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
18. Abdomen :
I : Distended (-), bowel pattern/movement (-), venectation (-)
P : Turgor decrease, tenderness (-)
P : Hypertympanic, Liver Dullness (-) , Shifting Dullness (-)
A : Bowel sound (-) Increased
19. Local Status
Perineal Region :
I : Anal dimple (+), Bucket Handle (-), median pararaphae (+), no
pulsation punctum rectum , there’s no fistulas that visualized
External genitalia:
Male, penis (+), Scrotum with 1 testicle at the right sac, MUE (+) at
anterior glans. Feces (+) at the MUE.
24. Operation Report : (11.10 – 13.00 WIB)
• Patient laid supine under General anesthesia
• Antiseptic & Aseptic operation area
• Performed incision between umbilcal and anterior superior left ilacal spine.
• Performed transversal incision layer by layer (Cutis, Subcutis, Champer’s
fascia, Scarpa’s fascia, Oblique externus abdominis muscle, Oblique
internus abdominis muscle, Transversus abdominis muscle, Tranversal
fascia, Preperitoneal fascia, Peritoneum), until peritoneum.
• Open the peritoneum yellowish clear fluid came out from the abdominal
cavity, Identification sigmoid colon.
• Made bridging, maturation at tegel side
• Performed incision at sigmoid colon
• Maturation on 8 side
• Bleeding control
• Operation finished
25. Post operative diagnosis: (13.00 WIB)
Malformation anorectal with rectourethra fistule
Undecended Left Testis
Post colostomy
26. Management post operation : (13.10 WIB)
• Dx :
– S : -
– O : -
• Tx :
– Keep warmth
– Cefotaxime 150 mg/12 hours intravenous
– Paracetamol 30 mg / 8 hours orally
– ASI ad libitum after 24 hours post operation
NICU
• Mx :
– General condition, vital sign, vitality stoma and production
• Ex :
– Diagnose, operation findings, stoma care, planning for further treatment
27. Follow Up Day 2
S : -
O : General condition : good
Vital signs :
•RR : 40 x/mnts (regular, adequate depth of breath, no retraction)
•HR : 150 x/mnts (regular, adequate tone and volume)
•T : 37 ºC (A)
Localized status of abdominal region :
I : flat, look stoma with stoma bag (+), feces production ± 15 cc/9 hours
Pa : Tenderness (+), defans musculare (-)
Pe : tympani (+)
A: Bowel sound (+) N, metallic sound (-)
Urinary output : 1,83 cc/kgBW/hour
A :
Malformation anorectal with rectourethra fistule
Undecended Lef Testis
Post colostomy Day 1
P :
– Keep warmth
– Cefotaxime 150 mg/12 hours intravenous
– Paracetamol 30 mg / 8 hours orally
– ASI ad libitum
