Morning Report

Sunday, August 27th 2017

Team on duty
dr. AA Ahmad Dimyanti (Chief)
dr. Tommy Rivelino (Chief)
dr. Raja Raharja Marlunglung purba (Jaga 1)
dr. Aswad Affandi (Jaga 1)
dr. Andri Feisal Nasution (Jaga 2)
dr. Kas Mulyadi (Jaga 2)
dr. Andrian (Jaga 3)
dr. Ahmad Mutadi (Jaga 3)
dr. Syahmardani Ibnu (Jaga 4)
dr. San Winata Badiri (Jaga 4)
dr. Muhammad Arafat Muchtar (Jaga 5)
dr. T. Fenny Nohera (Jaga 5)
dr. Idham Adyasa Manggala Putra (Jaga 6)
RSUDZA dr. Mayenru Dwindra (Jaga 6)
NoS Distribution of surgery patient Room Total

1 Emergency room patient 16 Patients

2 Hospitalize 7 Patients
3 Out of clinic 9 Patients
4 Refuse medical advice 0 Patients
5 Passed away

6 Hospitalize room Jeumpa 1 28 /28 bed

Jeumpa 2 28 /28 bed

Jeumpa 3 28 /28 bed

Jeumpa 4 28 /28 bed

PJT 28 / 28 bed
ICU 5 Patients

ICU C 2 Patients

ICCU 0 Patients
PICU 2 Patients
NICU 3 Patients
 Kasno/ 57 yo/ Emfisema Subcutis Bilateral + Pneumothoraks Post Mediostomy/
POD 4
Mariani/ 49 yo/ ICH at the left Ganglia Basal region due to Hemoragic Stroke
Post Craniectomy ICH Evacuation / POD 6
ICU Rabumah/ 77 yo/ defect at the facialis region Post Wide Excision +Limited
ADULT Maxilotomi + Post local flap
Faula/ 35 yo/ ICH at the right Temporal region Post Craniectomy ICH
evacuation/ POD 2
Jasmani/ 55yo/ Post laparatomi eksplorasi due to general peritonitis due to
perforasi gaster/ POD 0

M. Ali Gade/ 58 yo/ Moderate Head Injury + ICH + SDh at the right
ICU Temporoparietal region Post Craniectomy ICH vecuation.
CARDIAC Erdi/ 32 yo/ Fracture Maxilla Lefort II + Fracture Zygomaticomaxilary Complex +
ICH + Open Depressed Fracture at the left Frontal region + Post Craniectomy
ICH evacuation/ POD 8

3
 Syarwani Umar/ 2 yo/ Ascitess + Intra Abdomen Tumour due to Neuroblastoma
PICU Post Laparotomy Exploration + Biopsy/ POD 1
Muhammad Alif Syakira/ 1 mo/ Post WSD due to empiema at the right
thoracal region/ POD1

NICU By. Senang Hati/ 5 days/ Post VP Shunt + Repair Meningoenchepalocele

Hydrochepalus/ POD 4
Khaira Nayyara/ 22 days/ Atresia Ani with Vestibuler Fistel Post Colostomy/
POD 2
By. Intan Yunidar/ 5 days/ Hydrocephalus Congenital Post VP Shunt/ POD 2

4
 Patient identity
Name : Birrul Walidain
Age : 2 months old
Sex : Boy
Address : Blang Puuk Nigan
Seunangan, Nagan Raya
Body weight : 5,1 kgs
CM : 1140413
Fathers phone : 085210257219
Admisssion Time : 24.57 WIB
 Time Response
Date/hour Examinati Laboratory Radiology Hour of Date/ DPJP
patient came on hour Diagnost hour
Examination Examination
to ER ics patient
out
Send Result Send Result from ER

27/08/2017 01.00 WIB 01.05 02.30 01.10 02.30 02.30 WIB 15.30 dr. Muntadhar
00.57 WIB WIB WIB WIB WIB WIB Sp.B, Sp.BA
Chief complaint
Abdominal distension

Patient illnes History

The patient was referred from Meulaboh
distric hospital to Zainoel Abidin Emergency
Room with a chief complaint abdominal
distension since 3 days ago.
 According to the mother, since 3 days ago the
baby cant defecation and his abdomen
became distension.
History of greenish vomiting (+)
There was history of colicky pain
 Physical examination
Suckling Reflex : weakness
Grasping Reflex : weakness
Crying : weakness
General appearance : Moderate
Pulse : 140 beats / min
Respiratory rates : 36 breaths/min
Body temperature : 36,5 oC
L/S at abdominal region
I : Distension, visible peristaltic (+).
A : Bowel sound increase
P : Musculaire rigidity (-), dance sign (+),
Sausage like mass sign (+)
P : Tymphani (+)

Digital Rectal Examination :

Tonus Sphincter ani was tight
Recti Ampulla was empty
Recti mucose smooth
Glove : currant jelly stool (+)
Assessments:
Abdominal distension due to
dd : 1. suspect intussusception
2. midgut volvulus
 Management
Stop Oral Intake
IVFD 4:1 500 cc/24 hours
Urinary Catheter : initial urine 10 cc
Hour Urine
NGT Decompression 01.00 8 cc
02.00 7 cc
Inj. Ceftriaxone 250 mg 03.00 8 cc
04.00 8 cc
Inj. Metamizole sodium 50 mg 05.00 10 cc
06.00 8 cc
Laboratory examination 07.00 7 cc
08.00 8 cc

Radiology examination 09.00 8 cc

10.00 7 cc
11.00 8 cc
12.00 7 cc
13.00 8 cc
14.00 8 cc
 Laboratory result
Hb : 7,5 g/dl transfusion
White blood count : 10.500/ul
Platelet : 277.000/ul
Ht : 22 %
CT : 7 minute
BT : 2 minute
Glucose ad random : 86 mg/dL
Sodium : 138 meq/L
Potassium : 4.4 meq/L
Chloride : 96 meq/L
Radiology Result :
Baby Gram
Air distribution not until distal colon
Dilatation of bowel

USG
Pseudokidney sign (-)
Target sign (-)
Corkscrew (+)
Diagnose :
Abdominal distension due to
dd : 1. suspect intussusception
2. midgut volvulus
Anemia

Consult to pediatric surgery division :

Laparotomy exploration emergency
 Intra operative
Patient was supine position with general anesthesia.
Aseptic and antiseptic procedure.
Perfomed supraumbilical transverse incision deeper
until peritonium
Peritonium is opened
Performed exploration from treitz ligament until distal
Found volvulus 20 cm from ICJ, blackness with size
20 cm
Ileum resection 20 cm from ICJ to the proximal, and
performed ileostomy end stoma
Performed appendectomy
Abdominal cavity was rinse with normal saline until
clean
Wound operation closed by primary sutured
Post operative diagnosed
1. Volvulus at the Ileum terminal ( ICD 10 CM
K562)
2. Anemia ( ICD 10 CM D64.9)
 Follow Up
Date S O A P
30/08/2017 Pain (-) Sensoium : CM Post laparatomy IVFD 4:1 500 cc /24
POD II HR : 110 beat / minute exploration + hr
PICU RR : 36 beat / minute ileostomy end stoma Inj.Ceftriaxone 250
T : 36,5 0c + appendectomy due mg/12 hour
to Metronidazole Inj. 50
1. Volvulus at the mg / 8 hours
L/S at abdomen Ileum terminal Inj.Metamizol sodium
I : Distention (-), wound ( ICD 10 CM 562) 50 mg/8 hour
was dry 2. Anemia ( ICD 10
A : Bowel sound (+) CM D64.9) Corection Kalium
P : Pain (-), 3. Hypoalbuminemia Corection albumin
P : Thympani (+) ( ICD 10 CM E88
4. Hypokalemia ( ICD LAB 28/08/2017
10 CM E87.6) Hb: 12.1 g/dl
WBC: 6.600 /ul
Platelet:321.000/ul
Ht: 35 %
Albumin : 2.49 g/dL
Sodium: 132 meq/L
Potassium: 2.7 meq/L
Chloride : 105 meq/L