Emergency Report
September 2nd 3th 2016
Resident on duty:
dr. Shanti Fernandez
Coass on duty :
Barra, Aldish, Dewi, Irfan,
Christi
General Surgery
Digestive Surgery
Thorax Cardiovascular Surgery :
Plastic Surgery
Urology Surgery
Neuro Surgery
Pediatric Surgery
Total
:
:
2
:
Oncology Surgery
Orthopaedy
Patient List
No
Identity
1.
Mr. Abdul
Azis/ 64
y.o
Admission
to ER
September
2nd 2016
Diagnose
Difuse Peritonitis e.c susp.
Perforation hollow viscus +
Hipovolemik syok no respon +
AKI
Treatment
VS Obs
O2
Head up 30 deg
IVFD NS
Antibiotic
H2 blocker
Complete blood
count
X-Ray
CT - Scan
NGT - Urine
Catheter
Co.to Digestive
surgery KIE
Patient discharge
by request
Patient List
No
2.
Identity
Mrs.
Rasinah/
46 y.o
Admission
to ER
September
2nd 2016
Diagnose
Moderate Head Injury + SDH
at Right Frontotemporal (16cc)
+ ICH at Left parietal (6cc) +
edem cerebri + Midline shift to
the left 2 mm
Treatment
VS Obs
VS GCS
O2 3lpm
Head up 30 deg
IVFD NS
Antibiotic
Analgetic
H2 blocker
Manitol
Complete blood
count
X-Ray
CT Scan
DC
Co.to Neuro
surgery
Pro Cito Craniotomi
evacuation
Post Op ICU
Patient List
No
3.
Identity
Admission
to ER
Mrs.
September
Faridah/ 48 2nd 2016
y.o
Diagnose
Mild Head Injury + fr.
Maxilozygomaticus + Rima
orbita
Treatment
IVFD NS
Antibiotic
Analgetic
H2 blocker
O2 2 lpm
Complete blood
count
Head CT Scan
Co.to Neuro
surgery
Conservative
Co. to Plastic
Surgery
Hospitalized
Patient List
No
Identity
Admission
to ER
4.
Mr Pandi /
55 y.o
September
2nd 2016
Diagnose
Abdominal pain e.c
susp.peritonitis e.c perforasi
appedicytis dd abdominal TB
+ Right Contracted kidney/
nephritis chronis et chronic
cystitis
Treatment
IVFD RL
Antibiotic
Analgetic
H2 blocker
Complete blood
count
Co. to Digetive
Surgery
Patient List
No
5.
Identity
Admission
to ER
Mr Farhan / September
60 y.o
2nd 2016
Diagnose
SOL Supratetorial
Treatment
IVFD NS
Kortikosteroid
Antibiotic
Analgetic
H2 blocker
Complete blood
count
Co. to Neuro
Surgery
Patient discharge
by request
1. Tn.Abdul Azis/ 64 y.o
Chief Complain :
Decrease of conciousness
Current History :
Since 15 minutes before admission, patient got
decrease of conciousness while he brought to Ulin
hospital. He got pain at his abdomen since a day
ago. He has hospitalized for a day at RS Datu
Sanggul Rantau. Before he got pain, he
complained about defecate 5 times, and last
defecation was a day ago. Nausea (+), vomiting
3 times (+), fever (+) since one day ago . Then he
brought to Ulin General Hospital for further
treatment.
Vital sign
BP: immeasurable
Hr: 83 tpm
RR: 28 tpm
T 36 0C
Phisic
Diagnostic
Head
:simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)
Chest
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi , no wheezing
Abdomen
I : distension (+) flat.
A : Bowel sound (-)
P : defance muscular (+) at whole abdomen,
P : Hyperthympani (+)
Head
General Status
Extremities
cold extremities, edema (-), parese (-)
Clinical picture
DRE : normal sphyncter tone,
smooth mucosa, mass (-),
rectal vault wasnt collapse,
tenderness (-)
Gloves : feces (+), blood (-),
secret (+)
Laboratory
Examination
Result
Normal value
hemoglobin
16.0
11.00-16.00
g/dl
Leucosit
7.9
4.0-10.5
Thousand /ul
eritrosit
5.41
4.50-6.00
milion /ul
hematocrit
44.6
42.00-52.00
Vol%
trombocit
171
150-450
Thousand /ul
Random Blood
Glucose
88
<200
Mg/dL
SGOT
105
0-46
U/I
SGPT
89
0-45
U/I
Urea
147
10-50
Mg/dL
Creatinine
3.5
0.7-1.4
Mg/dL
HBs Ag Ultra
Negative
X ray
Working Diagnosis
Difuse Peritonitis e.c susp.
Perforation hollow viscus +
Hipovolemik syok no respon +
AKI
MANAGEMENT
VS Obs
O2
Head up 30 deg
IVFD NS
Antibiotic
H2 blocker
Complete blood count
X-Ray
CT - Scan
NGT - Urine Catheter
Co to Digestive Surgery KIE
Patient Discharge by request
2. Mrs. Rasinah/ 46 y.o
Chief Complain :
Decrease of conciousness
Current History :
Since 30 minutes before admission, patient got
accident. He was a ride on a motorcycle with her
husband. helmet (+), and hit another motorcylce
from side back direction. The mechanism of
trauma, patient was fall down at ground. history
of unconsciousness (-) history of vomiting (+) at 3
times, history of bleeding from ear nose and
mouth (-/+/-). After the accident, Patient refered
to Bhayangkara hospital and patient brought to
Ulin for further treatment
Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP : 140/90 HR : 86x/m;
D : PCS 14 E3V5M6, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(-/-) BR (+)
Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal 2 hours before accident
E = Environment on the street
Secondary
survey Head
Head
:simetric, normocephal, brill haematom (-) batle
sign (-) , BO(-/-) BR(+), V.laceratum a.r Temporoparietal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)
General Status
Chest
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi , no wheezing
Abdomen
I : distension (-) wound (-) hematoma(-)
A : Bowel sound normal
P : defence muscular (-) tenderness (-) mass (-)
P : Tymphani (+)
Extremities
warm extremities, edema (-), parese (-)
Clinical picture
Laboratory
Examination
Result
Normal value
hemoglobin
12,4
11.00-16.00
g/dl
Leucosit
15,1
4.0-10.5
Thousand /ul
eritrosit
4.20
4.50-6.00
milion /ul
hematocrit
37,8
42.00-52.00
Vol%
trombocit
348
150-450
Thousand /ul
Random Blood
Glucose
128
<200
Mg/dL
SGOT
52
0-46
U/I
SGPT
49
0-45
U/I
Urea
33
10-50
Mg/dL
Creatinine
0,9
0.7-1.4
Mg/dL
Ct Scan
Working Diagnosis
Moderate Head Injury + SDH at
Right Frontotemporal (16cc) +
ICH at Left parietal (6cc) + edem
cerebri + Midline shift to the left
2 mm
MANAGEMENT
VS Obs
VS GCS
O2 3lpm
Head up 30 deg
IVFD NS
Antibiotic
Analgetic
H2 blocker
Manitol
Complete blood count
X-Ray
CT Scan
DC
Co to Neuro Surgery Pro Cito Craniotomi evacuation , post op ICU
3. Mrs. Faridah/ 48 y.o
Chief Complain :
Headache
Current History :
Since 30 minutes before admission, patient got
accident at pramuka street. He was a ride on a
motorcycle. helmet (+), and suddenly fall down
and her head hitted by ground. The mechanism of
trauma, patient was fall down at ground. history
of unconsciousness (+) at 15 minutes. history of
vomiting (+) at 1 times, history of bleeding from
ear nose and mouth (+/-/-). After the accident,
Patient brought to Ulin for further treatment
Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP : 110/80 HR : 92x/m;
D : PCS 15 E4V5M6, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(+/+) BR (-)
Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal 2 hours before accident
E = Environment on the street
Secondary
survey Head
Head
:simetric, normocephal, brill haematom (-) batle
sign (-) , BO(+) BR(-) excoriated wound (+)
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)
General Status
Chest
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi , no wheezing
Abdomen
I : distension (-) wound (-) hematoma(-)
A : Bowel sound normal
P : defence muscular (-) tenderness (-) mass (-)
P : Tymphani (+)
Extremities
warm extremities, edema (-), parese (-)
Maxilofacial status
At rima orbita : deformity (-), swelling
(-), bone discontinuity (-), diplopia (-)
At zygoma: deformity (-), swelling (-),
step off defect (-), crepitation (-)
At maxilla (S) : deformity (-), open
wound (-), swelling (+), floating (+),
tenderness (+), crepitation (-), bone
discontinuity (-), step off defect (-),
floating maxilla (-)
At mandibula: deformity (-), open wound
(-), swelling (-)
Clinical picture
CT Scan
Skull AP
Laboratory
Examination
Result
Normal value
hemoglobin
12,3
11.00-16.00
g/dl
Leucosit
17,3
4.0-10.5
Thousand /ul
eritrosit
3,64
4.50-6.00
milion /ul
hematocrit
37
42.00-52.00
Vol%
trombocit
229
150-450
Thousand /ul
Random Blood
Glucose
184
<200
Mg/dL
SGOT
37
0-46
U/I
SGPT
29
0-45
U/I
Urea
31
10-50
Mg/dL
Creatinine
0,7
0.7-1.4
Mg/dL
Working Diagnosis
Mild Head Injury + fr.
Maxilozygomaticus + fr. Rima
orbita
IVFD NS
Antibiotic
Analgetic
H2 blocker
O2 2 lpm
Complete blood count
Head CT Scan
Co.to Neuro surgery
Conservative
Co. to Plastic Surgery
Hospitalized
4. Mr. Pandi/ 55 y.o
Chief Complain :
Pain at right lower abdomen
Current History :
Since 2 day ago before admission, she felt pain at
his lower right abdomen. The pain was initially
felt at epigastric region, and then moved and
remained at right lower abdominal region. The
pain not accompanied of History Nausea (-),
vomiting (-), fever (-), History of jaundice (-).
There were no complaint in defecating. History of
use analgetik drugs (-). He was brought to
Amuntai Hospital, and he was hospitalized for 2
day and then He refered to ulin general hospital
Vital sign
BP: 130/90 mmHg
Hr: 86 tpm
RR: 20 tpm
T 36,5 0C
Phisic
Diagnostic
Head
Head
:simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi (+/-), no wheezing (-/-)
General Status
Chest
Abdomen
Extremities
I : distension (-) flat.
A : Bowel sound (+)
P : defance muscular (+) at Mc Burney Sign, Psoas sign
(+), Obturator sign (+)
P : Thympani (+)
Warm extremities, edema (-), parese (-)
Clinical picture
Local Status :
- Abdominal region :
distension (-) flat, Bowel
sound (+)
defance muscular (+) at Mc
Burney Sign, Psoas sign (+),
Obturator sign (+),
Thympani (+)
DRE : normal sphyncter
tone, smooth mucosa,
rectal vault wasnt
collapse, tenderness (-)
, Gloves : feces (+),
blood (-), secret (-)
Laboratory RSU Pambalah Batung
31-8-2016
Examination
Result
Normal value
Hemoglobin
13,9
11.00-16.00
g/dl
Leucosit
9,0
4.0-10.5
Thousand /ul
eritrosit
4.94
4.50-6.00
milion /ul
hematocrit
30,1
42.00-52.00
Vol%
trombocit
299
150-450
Thousand /ul
Random Blood
Glucose
74
<200
Mg/dL
SGOT
26
0-46
U/I
SGPT
30
0-45
U/I
Urea
30,6
10-50
Mg/dL
Creatinine
1,0
0.7-1.4
Mg/dL
Laboratory RSU Pambalah Batung
2-9-2016
Examination
Result
Normal value
Hemoglobin
12,0
11.00-16.00
g/dl
Leucosit
7,5
4.0-10.5
Thousand /ul
eritrosit
4.29
4.50-6.00
milion /ul
hematocrit
30,9
42.00-52.00
Vol%
trombocit
196
150-450
Thousand /ul
Random Blood
Glucose
113
<200
Mg/dL
SGOT
15
0-46
U/I
SGPT
13
0-45
U/I
Urea
24
10-50
Mg/dL
Creatinine
1,13
0.7-1.4
Mg/dL
X-Ray
Usg Abdomen
Working Diagnosis
Abdominal pain e.c
susp.peritonitis e.c perforasi
appedicytis dd abdominal TB +
Right Contracted kidney/ nephritis
chronis et chronic cystitis
MANAGEMENT
IVFD RL
Antibiotic
Analgetic
H2 blocker
Complete blood
count
Co. to Digetive
Surgery
5. Mr. Farhan/ 56 y.o
Chief Complain :
Decrease of conciousness
Current History :
Since 1 day ago before admission, suddenly
patient got a decrease of conciousness, before
that, patient got vomiting 2 times with
continously of headache and not cured with
medicineThe pain felt since 1 year ago. Short of
breathness (-), Parase (-), convulsi (-), fever (-).
There were no complaint in defecating. History of
HT (-), History of DM (-), history of trauma
accident (-) He was brought to neurologist and
patient brought to Banjarbaru Hospital, and then
Vital sign
BP : 140/90
Hr: 88 tpm
RR: 24 tpm
T 36 0C
Phisic
Diagnostic
Head
:simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)
Chest
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-/-), no wheezing (-/-)
Abdomen
I : distension (-) flat.
A : Bowel sound (+)
P : defance muscular (-)
P : Thympani (+)
Head
General Status
Extremities
Warm extremities, edema (-), parese (-)
Clinical picture
Laboratory
Examination
Result
Normal value
hemoglobin
18,1
11.00-16.00
g/dl
Leucosit
10,2
4.0-10.5
Thousand /ul
eritrosit
5,65
4.50-6.00
milion /ul
hematocrit
55,9
42.00-52.00
Vol%
trombocit
338
150-450
Thousand /ul
SGOT
30
0-46
U/I
SGPT
30
0-45
U/I
Urea
75
10-50
Mg/dL
Creatinine
1,0
0.7-1.4
Mg/dL
X-Ray
CT Scan
Kesimpulan :
Oligodendroglioma
Working Diagnosis
SOL Supratetorial
MANAGEMENT
IVFD NS
Kortikosteroid
Antibiotic
Analgetic
H2 blocker
Complete blood count
Co. to Neuro Surgery
Patient discharge by request
