Case Report Sunday, June 10th 2012

Team on duty : Fahrul R, MD Hasan S, MD Andria S, MD Tugam UB, MD Rynaldi, MD

No 1

Distribution of the surgical patient The Patient came to emergency room - Hospitalized - Out of clinic patient - Move to the other Hospital

Place

Number Of 2 Patient 2 Patient - Patient

-HCU
-ICU 2 Death 1

4 Patient / 4 bed
3 Patient / 3 bed Syarifuddin 59 years old Dx: Haemorragik stroke + acute hydrocephalus,COD : Pneumonia 28 Patient / 28 bed 27 Patient / 28 bed

A number of patient that hospitalized

JP 1 JP 2

JP 3
JP 4

28 Patient / 28 bed
17 Patient / 28 bed

Patien identity
Name Age Sex Address : M.Revaldy : 5 years old : Male : Ds. Dsn Tuan Panterik Jaya, Aceh Jaya : 0-90-28-77 : 085292326624

MR HP

Chief complaint
Abdominal distention

Presenting history
The patient referred from RSIA Banda Aceh with a chief complaint abdominal distention since 7 days ago. Abdominal distention became worst since 5 days ago and with no defecation, flatulance (+). History of blunt abdominal trauma for 10 days ago. And then the patient hospitalized for 7 days at RSIA Banda Aceh. There was history of fever, nausea and vomiting.

Physical examination
Vital Sign Consciousness Pulse Respiratory rate T rectal : Alert : 100 beats/minute : 24 breaths/minute : 37,2 C

S/L a/.r Abdomen Inspection : Distention (+), darm contour (-), darm steifung (-). Auscultation : Peristaltic (+) decreased Palpation : Muscular rigidity (-) Percussion : Liver dullness (+)

Digital Rectal Examination Sphincter ani : loose Ampula recti : empty Mucosa : smooth Pain : (+) all region, At glove : faeces (+) blood (-)

Assessment
Partial mechanical bowel obstruction

Management
Stop oral intake IVFD RL Holiday-Zegar formulation : 10 kg x 100 cc = 1000cc 3kg x 50 cc = 150cc 1000cc+150cc = 1150 cc/ 24 hours In 6 hours : 1150cc / 4 = 287 cc / 6 hours Dehidration : 10 % 13000 cc x 10% = 1300 cc Total: 1300 cc + 287 cc = 1587 cc / 6 hours 264 cc / hours

Inj. Cefotaxime 500 mg Inj. Metronidazole 200 mg Inj. Metamizol sodium 250 mg NGT Insertion of urinary Catether

Hours 21.00 22.00

Urine production 15 cc 15 cc

23.00
00.00 01.00 02.00 03.00 04.00 05.00 06.00 07.00

30 cc
35 cc 40 cc 40 cc 40 cc 35 cc 35 cc 40 cc 40 cc

08.00
09.00

45 cc
55 cc

 Laboratory examination Radiologic examination Laboratory examination Hb : 11,7 gr/dl WBC : 6.300 /ul Platelet : 370.000 /ul HT : 38 % CT : 7 minutes BT : 2 minutes Glucose ad random: 97 gr/dl Clorida : 105 Mmol/L Kalium : 4,6 Mmol/L Natrium : 136 Mmol/L

Radiology examination X Ray Result : The dilated bowel Air distribution not until distal The thickness of the bowel wall Hearing bone (+) Multiple Step ladder (+) Air fluid level (+)
Consult to pediatric surgery division : Laparatomy exploration emergency

Operation Report
Patient in supine position with general anaesthesia A and Antiseptic procedure Perform transverse supraumbilical incision Incision deepened until peritoneum When Peritoneum was opened and flew up a serrous liquid 20 cc Abdominal cavity was rinse with warm normal saline Exploration from lig.Treitz to distal, founded multiple stenosis at ileum (4 place with 2 cm distance), about 40 cm from ileo-caecal junction. Perform resection ileo-ileal with end to end anastomose Performed patological examination. Exploration to solid organ there was no abnormality. Abdominal cavity was rinsed with warm normal saline until clean. Wound operation suture by primary suture

Diagnose post operative : Partial mechanical bowel obstruction due to multiple ileal stenosis. Follow Up
Date
12/06/2012

S
flatulance (+)

O General condition : good Pulse: 100 beats/minut e RR : 24 breaths/min NGT

a.r abdomen : I: symmetricaly A: bowel sound (+) P: liver dullnes (+) P: tymphani (+)

A Partial mechanical bowel obstruction due to multiple ileal stenosis.

P
IVFD 4 : 1 30 drip / minutes micro Ceftriaxone Inj 500 mg/8 hour Metronidazole 200 mg/8 hour Metamizole sodium 250 mg/12 hour

POD I

Patient Identity
: Akmal Juwanda : 24 years old : Male : Ds. Geulanggang Baroh Kec. Kota Juang, Bireun MR : 0-90-28-48 Phone : 085261161049 Driving license: (+) Name Age Sex Address

Chief complain Headache after trauma Presenting history of illness Patient was came to emergency room with a chief complain headache after trauma since 1 days ago. He was riding a motorcycle with helmet and suddenly felt down with his head hit asphalt. History decrease of consciousness (-), History of nausea and vomiting (-).

Physical examination
Primary Survey A: clear B: spontaneous, RR: 20 breaths/ minute C: Pulse 100 beats/minute D: GCS:15 (E4 M6 V5) ; isochoric pupil 3mm/3mm, lateralization (-), Light reflex +/+

 E: Localize state : The left occipital region: L: haematoma (+). F: Discontinuity of bone (+)

Assessments:
Mild head injury + close depressed fracture at the left occipital region.

Management
Stop oral intake Head up 300 02 4l/minute via canul IVFD Nacl 20 drips/minute Inj. Ceftriaxone 1g Inj. Ketorolac 30 mg Laboratorium examination Radiology examination

Laboratory examination
Hb White blood count Platelet Ht CT BT Blood glucose : 13,1 gr/dl : 9.300 /ul : 228.000 /ul : 37 % : 7 minute : 2 minute : 115 mg/dl

Radiology Examination
Head Ct Scan : SCALP haematoma at the left occipital region There was depressed fracture > 1 tabule at the left occipital region Sulcus and gyrus was normal There was no hiperdens abnormal Ventricle and cisterna system was normal There was no midline shift

Assessment: Mild head injury + depressed fracture at the left occipital region .
Consult to Neurosurgery division Craniotomy elevation depressed fracture

Intra operative Patient in supine position, extended to the right side, head up 30 0, with general anaesthesia. Aseptic and Antiseptic procedure. Perform lazy S incision until bone. Identified depressed fracture at the left occipital region Perform 1 burr-hole and bone was pulled out Performed dura hit stiches Wound rinse with perhydrol 3% + povidone iodine 10% + normal saline 0,9 % Bone flap was returned with mozaic position Operation wound was closed layer by layer with primary sutured

Post Operative Diagnose Depressed fracture at the left occipital region.

Patient follow up
Date 12/06/2012 POD II S headache decrease O General Condition good Pulse 96 beats/minute RR 18 breath/minute GCS=15 E4 M5 V6 isochoric pupil 3mm/3mm A Depressed fracture at the left occipital region. P IVFD Nacl 0,9% 20 drips/minute Inj ceftriaxone 1g /12 hours Inj ketorolac 30mg/ /8 hours diet 1800 kal.