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7/22/2019 EMG Report RSPAD April 11th , 2014.pptx
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Emergency ReportFriday, April 11th, 2014
Beriman Parhusip, dr
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Attendings On Duty
Pediatric surgery: dr. Irhamni, SpB, SpBA
Digestive surgery: dr. T. Suhardi, SpB-KBD
Orthopaedic surgery: dr. H. Satria, SpOT(K)
Plastic surgery: dr. Asrofi, SpB, SpBP
Neurologic surgery: dr. H. Setiajaya, SpBS
Oncologic surgery: dr. D. Hangesti, SpB-Onk
Thorax CV Surgery: dr. W. Hadi, SpB, SpBTKV
Urologic surgery: dr. Hariyono, SpU
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Patient Distribution
Out Patient : 0
In patient : 0
Operations : 2
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1. Mrs Refi, 22 y.oAdmission : 11-4-14; 11.30 a.m/MR 434603
CC: pain at whole abdomen
HT : Since 2 days prior to admission, she felt pain at
whole abdomen. The pain was initially felt at lower
abdomen and then spread to whole abdomen,continually, and became worse, followed by
undefecating, nausea (+), vomiting (-), fever(+). History
of late menstruation (-), trauma (-). History of
leuchorrhea (+). There was no complaint in urination.
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Physical Examination
General Status :
Alert
BP : 80/60RL 1500 cc110/70 mmHg PR : 120x/mnt RR : 24 x/mnt T : 37,0 0C
Conjuntivas were anemic (+)
Local Status :
At abdomen : distention, tense, bowel sound (+),
tenderness (+), rebound tenderness (+), muscular rigidity (+),mass (-)
DRE : normal sphincter tone, smooth mucosa, ampulla wascollapsed, mass (-), tenderness at all direction
Glove : stool (+), blood (-)
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Jenis Pemeriksaan
(Hematologi)
Hasil Nilai Rujukan
SGOT 15 < 35 U/L
SGPT 10
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Laboratory Finding
Hb : 9.5 gr/dL
Ht : 28 %
WBC : 19.000 /mm3
Plt : 419.000 /mm3
AST : 15 U/L ALT : 10 U/L
Na : 130 mmol/L
K : 4.2 mmol/L
Ur : 54 mg/dL
Kr : 2.1mg/dL Glucose : 271 mg/dL
PT : 11.7 sec (control 13,5)
aPTT : 30 sec (control 30,5)
PP test : negatif
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WD/
Diffused peritonitis due to suspect tuboovarial abcess rupture
DD/ mesenterial trombosis Sepsis
T/
NPO
Infusion RL 2000 cc
NGT and urine catheter insertion
Antibiotic
Analgetic
Consult to obgyn
Laparotomy exploration
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Obgyn consult
There were no deviation in obstetri and
gynecology departement
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Intraoperative finding
We found : Reddish peritoneal fluid 500 cc
Potruded a loop of ileum through mesoileal at 40 cmproximal to valvula Bauhini that caused ilealstrangulation
Ileal strangulated 180 cm Remaining intestine 190 cm (160 cm from lig. Treitz
+ 30 cm from v. Bauhini)
Organ solid within normal limit
Ovarium and tuba within normal limit
Intraoperative consult : none
Blood lost : 50 cc
Histophatology examination : none
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Post Op diagnosis :
Diffused peritonitis due to ileal strangulation
due to mesoileal hernia
Sepsis
Treatment :
Segmental ileal resection and ileoileal end to
end anastomosis
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Intraoperative Pictures
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2. Mrs,A. , 16 y.oAdmission : 11-4-14; 23.00 p.m/ MR 434194
CC: pain at left upper leg and wound at perineal region
HT : 6 hours prior to admission, when she was in theriding car with high velocity at Jagorawi toll road,
without seat belt, the car hit the left side of limitingroad bar, caused she got out of the car. The mechanismof injury was unknown. History of loss ofuncousiousness (-), vomiting (-), no bleeding from ears,nose or mouth. She felt of pain at her left upper leg andwound at perineal region. The patient was brought toBhayangkara Hospital, and then referred to GatotSubroto Hospital.
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Primary Survey :
A : clear
B : RR = 22x, symmetrical chest expansion, equal VBS
C : BP = 110/80 PR = 92x/m
D : GCS = 15, isochorepupils, 3/3 mm, LR +/+. Motoric parese -/-
Secondary Survey :
Left facialis : excoriation (+), hematoma (-)
Thorax : bruise (-)
Abdomen : bruise (+), flat, bowel sound (+) normal, tenderness (-)
Pelvic : bruise (-)
Perianal : vulnus (+) 2x2 cm, at 1 oclock direction, 1 cm from analverge direct to left major labium. External sphincter muscle wasintact
At left femur region : wound (-), deformity (+), tenderness (+), ROM
limited due to pain
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Pelvic and femur X-rays
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FAST
There were no fluids collection at hepatorenal
space, splenorenal space, or retrovesica space
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Laboratory Finding
Hb : 8.8 gr/dL
Ht : 27 %
WBC : 21.700 /mm3
Plt : 433.000 /mm3
AST : 177 U/L ALT : 99 U/L
Ur : 37 mg/dL
Kr : 0.8 mg/dL
Na : 135 mmol/L K : 3.7 mmol/L
Glucose : 159 mg/dL
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WD/
Closed fracture of left shaft femur at middle third, oblique
displaced Lacerated wound at perianal region
Anemia due to haemorrhagic
T/ Antibiotic and analgetic
Orthopedic : skin tractionORIF
Pediatric surgery : wound caredebridement + primary suture
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Intraoperative found
Orthopedic: Hematoma (+) 300 cc Fracture of middle third of left femur, oblique displaced
Pediatric :
Wound at perianal region 2x2 cm, at 1 oclock direction, 1 cmfrom anal verge to left major labium
Rupture of subcutaneus part of external sphinter muscle
Blood lost : 100 cm
Intraoperative consultation : none
Histophatology examination : none
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Thank You