EMERGENCY
REPORT
OCT 21H – 22TH 2017
Chief on Duty :
YULI
Coass on Duty:
AKBAR, FEBRI, FAUZAN
No Identity Admission to ER Diagnosis Treatment
1 Ny Isna/ 27 y.o Oct 30th 2017 Hemoroid Hemorroid supp 1x/day
Admitted 15.10 Internal grade IV
Consult to Digestive
Surgery :
Hospitalized
Pro Operation Electively
Patients discharge by
request
No Identity Admission to ER Diagnosis Treatment
2. Soirin/ 52 yo Oct 30th 2017 Mild Head Injury C spine control
(14) + Vulnus O2 2-4 lpm
Admitted 21.00 laceratum at Head Up 30 degrees
regio frontalis CBC
anterolateral Xray Thorax AP
dekstra Cervical Swimmer position
Ct head Trauma
Wound debridement
Wound hecting
IVFD Ns 20 tpm
Inj Ceftriaxon 2x1 gr
Inj Ranitin 3x30 mg
Inj Ketorolac 3x30 mg
Observation General state
Consult to Neurosurgery
Dept :
Hospitalized
No Identity Admission to ER Diagnosis Treatment
3 Child Shelsy A/ Oct 30th 2017 PO Repair vp O2 2-4 lpm
9 y.o shunt et causa IVFD D51/2 Ns 60 cc/ hours
Admitted 22.15 Hidrocephalus CBC
POD XVI + General state observation
Ependimoma
residif Consult to neurosurgery
dept :
Hospitalized
Dexametason Inj 3x 10 mg IV
Mr Soirin/ 52 y.o
Chief Complain:
Headache post motorcycle injury
History of Current Disease:
Patients complained about headache since 3 hours before
admitted. The accident mechanism is unknown, but the patient
was using a helmet, and the headache appears suddenly and
persistently, the complaint about headache are accompanied by
sudden vomiting as much as 2x in rsud ansari saleh. However,
until the patient's complaint for headache is reduced and
vomiting does not exist in RSUD Ulin Banjarmasin.
PRIMARY SURVEY
• A: Clear, with C Spine control
• B: RR: 23 tpm, regular, rh(-/-) wh(-/-), SpO2 99% without supply O2
• C: N: 65 bpm, strong, regular, BP: 120/80 mmhg
• D: GCS E3V5M6 BH (-/-) BO(-/-) BR (-/-) BS (-/-), pupil isokhor 3
mm/ 3 mm, pupil reflex (+/+)
Secondary survey:
A = (-)
M = (-)
P = (-)
L = Last meal 3 hours before accident
E = Environment on the street.
Physical Examination
• Head : simetric, there are multiple VL at regio fontalis anterolateral dekstra
• Eye : Anaemic conj. (-/-), brill hematoma(-/-), ishokor pupil
Head • Mouth : Pale Lips Mucous (-) dental loss (-) floating maxilla (-)
• Neck : Elevated JVP (-) 5+1 cmH20, bruises (-)
• I : symmetric respiratory movement, retraction (-), bruise (-)
Chest • P : symmetric VF
• P : Sonor at all lung fields
(pulmo and Cor) • A : symmetric VBS, no rhonchi, no wheezing, murmur (-) gallop (-)
• I : Looks flat, distension (-) bruises (-)
• A : Bowel sound normal
Abdomen • P : tenderness (-), defans muscular (-) Organ Enlargment(-)
• P : Timpani at all region
Extremities • Warm ekstremities (+) lateralization (-)
LOCAL STATE
I : Hiperemis(+) Vulnus
laceratum at regio frontalis
anterolateral dekstra
P : Tenderness with
diameter vulnus 5x2 cm and
subcutis base
NORMAL CT SCAN
Mild Head Injury (14) + Vulnus
laceratum at regio frontalis
anterolateral dekstra
C spine control IVFD Ns 20 tpm
O2 2-4 lpm Inj Ceftriaxon 2x1 gr
Head Up 30 degrees
Inj Ranitin 3x30 mg
CBC
Xray Thorax AP
Inj Ketorolac 3x30 mg
Cervical Swimmer position Observation General state
Ct head Trauma
Wound debridement Consult to Neurosurgery Dept
Wound hecting Hospitalized
Mrs Isna/ 27 y.o
Chief Complain:
Anus Pain
History of Current Disease:
Patients complained of pain in the anus about 4 days ago. Initially
the pain has been felt after giving birth to the first child 2 years ago,
where there is a lump in the anus. Initially the lump can intermittent
out for long periods of time and then the lump must be entered
manually and finally can not enter again. The pain are also
accompanied by bloody defects.
Vital Sign:
• GCS E4V5M6
• BP: 120/80 mmHg
• P: 82 bpm reguler strong
• RR: 24 tpm
• Temp: 36.8°C
• SpO2 99% without supply o2
Physical Examination
• Head : simetric, mesocephali (+)
• Eye : Anaemic conj. (-/-), brill hematoma(-/-), ishokor pupil. Light reflex (+/
Head +) direct indirect
• Mouth : Pale Lips Mucous (-) dental loss (-) floating maxilla (-)
• Neck : Elevated JVP(-), bruises (-)
• I : symmetric respiratory movement, retraction (-), bruise (-)
• P : symmetric VF
Chest • P : Sonor at all lung fields
• A : symmetric VBS, no rhonchi, no wheezing
• I : Looks flat, distension (-) bruises (-)
• A : Bowel sound normal,
Abdomen • P : tenderness (-) all regio , defans muscular (-) Organ Enlargment(-)
• P : Timpani at all region
• Warm ekstremities (+) lateralization (-)
Extremities • Extermities superior with IVFD line
ANUS LOCAL STATATE
I : Mass with ireeguler form,
cannot pull, hiperemis (-) blood
(-)
P : Tenderness (+)
Rectal Toucher
Spingter ani menjepit kuat
Mukosa recti Licin
Ampulla recti tidak licin
Nyeri di segala arah dan
tangan sukar masuk ke dalam
karena ada masa
Handscoon Feces (-) Darah
(+)
Diagnosis
Hemoroid Interna Grade IV
Management
•Hemorroid supp 1x/day
•Consult to Digestive Surgery :
•Hospitalized
•Pro Operation Electively
•Patients discharge by request
Child Shesly/ 9 y.o
Chief Complain:
Decrease of consciousness
History of Current Disease:
complained about the decrease of consciousness since 1 day ago
before admitted. Complaints arise slowly and continuous. The
patient can still respond the command to movement but hard to talk.
The present state of the body is just stiff
history 1x seizures in the hospital sampit and giving anti-seizure
medication
Patient post op repairvp shunt 14-10-2017 and in command to re-
control 2 november.
Vital Sign:
• GCS E3VxM6
• BP: 100/80 mmHg
• P: 102 bpm reguler strong
• RR: 19 tpm
• Temp: 36.9°C
• SpO2 99% with supply o2 nasal kanul 3-4 lpm
Physical Examination
• Head : simetric, mesocephali (+)
• Eye : Anaemic conj. (-/-), brill hematoma(-/-), pupil isocor (3m/3mm) Slow
Head light reflex
• Mouth : Pale Lips Mucous (-) dental loss (-) floating maxilla (-)
• Neck : Elevated JVP(-), bruises (-)
• I : symmetric respiratory movement, retraction (-), bruise (-)
• P : symmetric VF
Chest • P : Sonor at all lung fields
• A : symmetric VBS, no rhonchi, no wheezing
• I : Looks flat, distension (-) bruises (-)
• A : Bowel sound decreased, mettalic sound (-)
Abdomen • P : Supel , defans muscular (-) Organ Enlargment(-)
• P : Timpani at all region, asites (–)
Extremities • Warm ekstremities (+) lateralization (-)
CLINICAL FEATUR
Diagnosis
PO Repair vp shunt et causa
Hidrocephalus POD XVI +
Ependimoma residif
Management
O2 2-4 lpm
IVFD D51/2 Ns 60 cc/ hours
CBC
General state observation
Consult to neurosurgery dept :
Hospitalized
Dexametason Inj 3x 10 mg IV
