Morning Report
Tuesday, February 7th 2017
Team on duty
dr. Joko Siswanto (Chief)
dr. Lea Dharman Husein (Jaga 1)
dr. T. Ronasky (Jaga 2)
dr. Jauhari Deslo (Jaga 2)
dr. Reza Furqan (Jaga 3)
dr. Andri Feisal Nasution (Jaga 3)
dr. Ike Yoganita Bangun (Jaga 4)
dr. Avicena Gatot (Jaga 4)
RSUDZA dr. Iskandar Islam (Jaga 5)
dr. M. Iqbal (Jaga 6)
No Distribution of surgery patient Room Total
1 Emergency room patient 15 Patients
2 Hospitalize 8 Patients
3 Out of clinic 7 Patients
4 Refuse medical advice 1 patient
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 6 /28 bed
ICU 4 Patients
ICU C 2 Patients
ICCU 0 Patients
PICU 2 Patients
NICU 0 Patients
ICU • Zulkarnain/ 51yo/ post amputation above knee ec death limb pedis
ADULT sin/POD1
• Maryam/ 56yo/ post craniectomy ICH evacuation / POD 5
• Nurhasanah ismail/ 49 yo/ post craniectomy ICH evacuation/ POD 5
• Riska shinta/ 17 yo/ mediastinum tumor + respiratory failure / AD 5
ICCU
ICU • Riki Akbar/ 20 yo/ Post Sternotomy + VSD Closure dengan Goretex
CARDIAC patch ec VSD perimembrane / POD 0
• Sastra Wijaya/ 48 yo/ Post nephrolitotomy Sinistra + Hidronephrosis
Sinistra/ POD 0
PICU • Kayla Attaya / 4 mo/ post Chest tube insertion ec pleural efusion/
POD2
• Fathur Khairi/ 1mo/ post VP Shunt ec non Communicans
hydrocephalus/ POD 0
NICU
3
Patient identity
• Name : Faizin
• Age : 10 years old
• Sex : Male
• Address : Ds Blang Makmur, Kuala
Batee, Aceh Barat Daya
• MR : 1118625
• Phone : 085372290909
• Admission Time : 02.30 WIB
Time Response
Date/hour Examinatio Laboratory Radiology Hour Date/ DPJP
patient n hour Examination Examination of hour
came to ER Diagno patient
Send Result Send Result stics out from
ER
07/02/2017 02.30 WIB 02.40 03.40 Already Performed 02.30 08/02 dr. Zulkarnaini
02.30 WIB WIB WIB WIB /2017 Sp. OT
08.30
WIB
Chief complaint
Pain and difficult to move of the right leg
Presenting history
• Patient was referred from Tengku Pekan
Aceh Jaya distrik hospital to Zainoel Abidin
emergency room with chief complaint pain
and difficult to move of the right leg for 15
hours.
• He was walking on the street and
suddenly strucked with motorcycle from
the behind.
• History of decrease of consciousness (-)
• History of vomiting and nausea (-).
• Radiologi examination was already
performed from district hospital
Physical examination
• A : Clear
• B : Spontaneous, RR : 20 breaths/min
Right haemithorax Left haemithorax
Inspection Symmetrical, trachea in the middle, JVP was normal,
wound (-)
Palpation Crepitation (-), pain(-) Crepitation (-), pain (-)
Percution Sonor Sonor
Auscultation Vesiculer (+), Rhonci (-), Vesiculer (+), Rhonci (-),
Wheezing (-) Wheezing (-)
• C : BP : 100/70 Mmhg, HR : 80 beats /min
• D : GCS E4M6V5: 15, isochoric pupil
3mm/3mm, light reflex (+)/(+)
• E:
L/S at the right leg
•L : Lacerated wound (+) pin point, swelling
(+), deformity (+).
•F : Pain (+), NVD (-)
• M: ROM limited ( at the ankle joint )
Secondary survey :
• Head and neck : in normal limit
• Thorax :
Right haemithorax Left haemithorax
Inspection Symmetrical, trachea in the middle, JVP was normal,
wound (-)
Palpation Crepitation (-), pain(-) Crepitation (-), pain (-)
Percution Sonor Sonor
Auscultation Vesiculer (+), Rhonci (-), Vesiculer (+), Rhonci (-),
Wheezing (-) Wheezing (-)
• Abdominal : in normal limit
• Upper Extremity : in normal limit
• Lower Extremity :
L/S at the right leg
•L : Lacerated wound (+) pin point,
swelling (+), deformity (+).
•F : Pain (+), NVD (-)
• M: ROM limited ( at the ankle joint )
VAS : Moderate
Mild 1-3 Moderate 4-6 Severe 7-10
Non opioid + Opioid + nonopioid Opioid + nonopioid
adjuvant + adjuvant + adjuvant
- COX-2 - Codein - Oxycodone
- Ibuprofen - Propoxyphene - Morphine
- Aspirin - Hydrocodone - Hydromorphone
- Acetaminophen - Tramadol - Fentanyl
Radiology Examination
Cruris dextra Ap/Lat
• Discontinuity of the lower tibia fibula
Diagnose :
Open fracture of the lower third of the
right tibia and fibula grade II
Management :
• Stop oral intake
• Immobilization
• IVFD RL 20 drips/minutes
• Cefazoline Inj. 500 mg
• Ketorolac Inj. 10 mg
• Tetagam 250 IU
• Laboratory examination
Laboratory Result
• HB : 13,3 gr/dl
• HT : 40 %
• White blood count : 22,200 / mm3
• Platelet : 427.000 / mm3
• CT : 7‘
• BT :2’
• Glucose ad random : 154 mg/dL
Diagnose
Open fracture of the lower third of the
right tibia and fibula grade II (ICD 10 CM
S82)
Consult to Orthopedic surgery division:
• Debridement + ORIF today
