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EMERGENCY CASE REPORT

December, 18th-, 19th 2013

Resident On Duty : Dr. Alex


Chief On Duty : Galih rahman Co-ass On Duty : Rizky,adis, eby, alif

Minor Surgery Plastic Surgery Orthopaedi Urology Pediatric Surgery Neurosurgery Oncology Thorax & Cardiovascular Digestive

= = = = = = = = =

0 Patient 0 Patient 2 Patient 0 Patient 0 Patient 1 Patients 0 Patient 3 Patient 0 Patient

Total New Patients All Patients will be reported

= 6 Patients

No

Identity

Admission to E.R. Dec 18th 2013 at 10.30

Diagnosis

Treatment

Planning

1.

Mrs Asmanah/ 66 yo

moderete head injury ec ICH Regio pariental dextra + IVH et regio ventrikel lateral dextra and ventrikel 4

IVFD NaCL 0,9% 20 dpm Brain act 3x 500 mg Ranitidin 2x1 amp Ceftriaxone 2x1 gr Norages 3x1 amp Kalnex 3x1 Pro op EVD Cito Hospitalized

2.

Mr. Kaminto/ 48 yo

Dec 18th 2013 at 16.35

Close fraktur ramus pubis bilateral superior et inferior comunited displaced post sistostomi ec ruptur uretrha posterior

IVFD rl 20 tpm Lactor 2x1 mg Ranitidin 2x1 mg Bed rest Exam complate Laboratorium

No

Identity

Admission to E.R. Dec 18th 2013 at 20.20

Diagnosis

Treatment

Planning

3,

Mr. Agus salim/ 20 yo

Vulnus ictum et regio hemithoraks sinistra ICS suspek pneumothoraks +vulnus iktum et regio supra umbilikal suspct internal bleeding et causa organ ruptur holoviskus + vulnus scissum at regio brachii sinistra

Obs. Vital sign IVFD RL 20 tpm Inj. Ceftriaxon 2x1 gr Inj. Ketorolac 3x30 mg Inj. Ranitidin 2x50 mg -Hospitalized

Mr. Aan/ 20 yo

Dec 12th 2013 Close fraktur ramus pubis at 23.40 bilateral superior at inferior comunitif displaced

Bed rest Complete blood exam IVFD RL 20 dpm Inj. lactar 2x1 Inj Ranitidin 2x1

Mr. Hendri/21 yo

Dec 18 th at Vulnus ictum et regio flangk 23.45 dextra susp contusio pulmonal

IvFd rl 20 dpm Inj Ranitin 2x1 amp Inj Ketorolac 2x1 amp Inj Ceftriaxone 2x1 gr IvFd rl 20 dpm Inj Ranitin 2x1 amp Inj Ketorolac 2x1 amp Inj Ceftriaxone 2x1 gr Ro/ thorax/ 6 jam

6.

Mr. Agus/22 yo

Dec 19 th at Vulnus ictum et regio hemithorax 04.50 dextra

1. Mrs. Asmanah/ 66 yo / Dec 18th 2013 at 10.30


Chief Complain : penurunan kesadaran

History :

+ 10 hour before admission the patient complained headache and parese at foot and left of leg. Trauma (-), history of uncontrol hipertension (+), history of vomiting (), Patient then was brought to Ulin Hospital.

Primary Survey
A
Clear, snoring (-), gurgling (-), c-spine control (+) Clear, RR=22 bpm, symmetric respiratory movement, symmetric VBS BP : 150/100 mmHg Pulse rate : 80 bpm, regular GCS E2V5M2, round and symmetric pupils diameter (2mm/2m), light reflexes (+/+), no paralysis B

A M

P L
E

At the home

Secondary survey
Head/Neck
Eye : anemic conjunctivae (-/-), icteric sclera (-/-) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)

Chest

I : symmetric respiratory movement, retraction (-) P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen
Extremities

I : wound (-), distension (-), hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

See local status

Clinical Picture

Laboratory Finding
18/12/2013
Hb L E Ht Plt Ur Cr : : : : : : : 11.2 g/dl 13,8 ribu /ul 3,86 x 106/ul 34.1`% 246.000/ul 24 mg/dl 0,9 mg/dl

SGOT : 35 U/l SGPT : 30 U/l Glucose : 122 mg/dl Na/K/Cl: 141.1/4,0/103,3

CT SCAN (Dec 18th 2013)

FOTO thorax AP (Dec 18th 2013)

Working Diagnosis
moderete head injury ec ICH Regio pariental dextra + IVH et regio ventrikel lateral dextra and ventrikel 4

Management
IVFD NaCL 0,9% 20 dpm
Brain act 3x 500 mg Ranitidin 2x1 amp

Ceftriaxone 2x1 gr
Norages 3x1 amp Kalnex 3x1 Pro op EVD Cito Hospitalized

2. Mr. Kaminto/ 48 yo / Dec 18th 2013 at 16.35


Chief Complain : pain in waist

History : about ten hours before admission, when patient

riding motorcycle, suddenly he was hit by a truck from the right side, patient fall and his waist hip the road first. Patient also complain nausea (+) vomiting(-). Patient then was brought to banjarbaru hospital. Patient got sistostomi (+) in there. And suddenly then he brought Ulin hospital to get future treatment .

Primary Survey
A
Clear, snoring (-), gurgling (-), c-spine control (+) Clear, RR=20 bpm, symmetric respiratory movement, symmetric VBS BP : 100/60 mmHg Pulse rate : 64 bpm, regular GCS E4V5M6, round and symmetric pupils diameter (2mm/2m), light reflexes (+/+), no paralysis B

Secondary survey
Head/Neck
Eye : anemic conjunctivae (-/-), icteric sclera (-/-) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)

Chest

I : symmetric respiratory movement, retraction (-) P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen
Extremities

I : wound (-), distension (+), hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Warm extremity, oedem (-), parese (-)

Local Status
At left thigh
Look : swelling (-) wound (-) deformity (-) Feel : tendernes (+), distal sensibility (+) crepitation (-) Move : ROM is limited

Urologic status
CVA

I : mass (-/-), wound (-/-), hematom (-/-) Pa : unpalpable mass, pain with pressure (+/+) Pe : kidney knock pain (+/+)

I : mass (-/-), hematom (-/-),wound(-/-) Pa : ren / unpalpable mass , pain with pressure(+/+) Flank Area

I : flat, wound (-), hematom (-), tumor (-) Pa : mass (-), pain with pressure (-) Suprapubik

Genitalia

I : eritem (-), oedem (-), P : scrotum palpable two, right and left.

Clinical picture

Laboratory Finding
Hb L E Ht Plt Ur Cr : : : : : : : 8,8 g/dl 8,1 ribu /ul 3,13 x 106/ul 26,8`% 203.000/ul 30 mg/dl 0,3 mg/dl

SGOT : 16 U/l SGPT : 61 U/l Glucose : 114 mg/dl Na/K/Cl: 136.7/3.8/100,7

Laboratory Finding
URINALISA

Warna-kekeruhan : Kuning-Keruh BJ : 1.025 pH : 5.0 Keton : Negative Protein albumin : Negative Glukosa : Negative Bilirubin : Negative Darah samar : +3 Nitrit : Negative Urobilinogen : 0.2 Leukosit : Negative

URINALISA SEDIMEN

Leukosit : 1-2 Erythrosit : negative Silinder : negative Ephitel : 1+ Bakteri : negative Kristal : negative Lain-lain : negative

X-Ray

X-Ray

X-Ray

Working Diagnosis
Close fraktur ramus pubis bilateral superior et inferior comunited displaced post sistostomi ec ruptur uretrha posterior

Management
IVFD rl 20 tpm Lactor 2x1 mg Ranitidin 2x1 mg Bed rest Exam complate Laboratorium

3. Mr. Agus salim/ 20 yo / Dec 18th 2013 at 20.20


Chief Complain : open wound at histomach

History : five hours before admission, he was it by

unknown people at road to be beaten and attack the left chest. After that he was fall to road and complain about hard to breath. He also complain about open wound at his left arm that produce fresh blood. history of unconsiusness (-) vommiting (-). Patient go to Ulin Hospital then to get treatment.

History past Disease : Diabetes (-),Hipertension(-),

Ashtma (-) History of family disease : Diabetes (-),Hipertension(), Ashtma (-) H/ same disease (-)

Primary Survey
A
Clear, snoring (-), gurgling (-), c-spine control (+) Clear, RR=28 bpm, symmetric respiratory movement, symmetric VBS BP : 100/60 mmHg Pulse rate : 96 bpm, regular GCS E4V5M6, round and symmetric pupils diameter (2mm/2m), light reflexes (+/+), no paralysis B

Secondary survey
Head/Neck
Eye : anemic conjunctivae (-/-), icteric sclera (-/-) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)

Chest

I : symmetric respiratory movement, retraction (-) P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen
Extremities

I : wound (-), distension (+), hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Warm extremity, oedem (-), parese (-)

Clinical Picture

Laboratory Finding
Hb L E Ht Plt : 14,4 g/dl : 8,5 ribu /ul : 4.46 x 106/ul : 41,4.1`% :299.000/ul SGOT : 30 U/l SGPT : 12 U/l Glucose : 154 mg/dl Na/K/Cl: 140,7/3.6/100

Working Diagnosis
Vulnus ictum et regio hemithoraks sinistra ICS suspek pneumothoraks +vulnus iktum et regio supra umbilikal suspct internal bleeding et causa organ ruptur holoviskus + vulnus scissum at regio brachii sinistra

Management
Obs. Vital sign CTT insertsen NGT+ Catether urin IVFD RL 20 tpm Inj. Ceftriaxon 2x1 gr Inj. Ketorolac 3x30 mg Inj. Ranitidin 2x50 mg Rongten post CTT - Hospitalized

4.Mr. aan/20 yo/ Dec 18th 2013 at 23.40


Chief Complain : pain of pelvic

History :

About 1 hours before admission, patient had work accident. working in the building, dropped from a height of 5 meters, with buttocks first fall. the patient can not move his leg. History of unconsciousness (-), vomiting (-), bleeding nouse / ear / mouth (-/-/-). Patient then was brought to Ulin Hospital to get treatment.

Primary Survey
A
Clear, snoring (-), gurgling (-), c-spine control (+) Clear, RR=21 bpm, symmetric respiratory movement, symmetric VBS BP : 100/70 mmHg Pulse rate : 96 bpm, regular GCS E4V5M6, round and symmetric pupils diameter (2mm/2m), light reflexes (+/+), no paralysis B

A M

P L
E

At work

Secondary survey
Head/Neck
Eye : anemic conjunctivae (-/-), icteric sclera (-/-) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)

Chest

I : symmetric respiratory movement, retraction (-) P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen
Extremities

I : wound (-), distension (-), hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

See local status

Scrotal

Butterfly hematom (-)

Perineal

Perineal hematom(-)

OUE

Meatal bleeding (+)

Local Status
At left thigh
Look : swelling (+) wound (-) deformity (+) Feel : tendernes (+), distal sensibility (+) crepitation (-) Move : ROM is limited due to pain

Clinical Picture

Laboratory Finding
Hb L E Ht Plt : : : : : 14,2 g/dl 9,4 ribu /ul 4,80 x 106/ul 41.6 vol% 220.000/ul

X-Ray

Management
- Bed rest Complete blood exam IVFD RL 20 dpm Inj. lactar 2x1 Inj Ranitidin 2x1

5.Mr. Hendri/21 yo/ Dec 18 th at 23.45


Chief Complain : pain of left chest

History :

About one hours before admission, patient had traffic accident. patient stabbed in the left chest, previously the patient drinks alcohol, patient complain pain of the left chest. History unconsciousness (-), vomiting (-), bleeding nouse / ear / mouth (-/-/-). Patient then was brought to Ulin Hospital.

Primary Survey
A
Clear, snoring (-), gurgling (-), c-spine control (+) Clear, RR=24 bpm, symmetric respiratory movement, symmetric VBS BP : 120/90 mmHg Pulse rate : 78 bpm, regular GCS E4V5M6, round and symmetric pupils diameter (2mm/2m), light reflexes (+/+), no paralysis B

A M

P L
E

On the road

Secondary survey
Head/Neck
Eye : anemic conjunctivae (-/-), icteric sclera (-/-) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)

Chest

I : symmetric respiratory movement, retraction (-) P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen
Extremities

I : wound (-), distension (-), hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

See local status

Local Status
At left hand
Look : swelling (-) wound (-) deformity (-) Feel : tendernes (-), distal sensibility (-) crepitation (-) Move : ROM is limited

Clinical Picture

Laboratory Finding
Hb L E Ht Plt Ur Cr : : : : : : : 9,9 g/dl 9,8 ribu /ul 4,72 x 106/ul 30,8 vol% 363.000/ul 49 mg/dl 1.3 mg/dl

Glucose : 112 mg/dl PT : 11.7 mg/dl APTT : 23.9 mg/dl Na/K/Cl: 140.9/4.4/78

X-Ray

Working Diagnosis
Vulnus ictum et regio flangk dextra susp contusio pulmonal

Management
IvFd rl 20 dpm Inj Ranitin 2x1 amp Inj Ketorolac 2x1 amp Inj Ceftriaxone 2x1 gr

6. Mr agus/22 yo/ Dec 19 th at 04.50

Chief Complain : pain of left stomatch


History :

About 0,5 hours before admission, patient patient climb over the fence, and slipped and impaled, blown admitted patient, Patient history unconsciousness (-), vomiting (-), bleeding nouse / ear / mouth (-/-/-). Patient then was brought to Ulin Hospital.

Primary Survey
A
Clear, snoring (-), gurgling (-), c-spine control (+) Clear, RR=21 bpm, symmetric respiratory movement, symmetric VBS BP : 100/70 mmHg Pulse rate : 96 bpm, regular GCS E4V5M6, round and symmetric pupils diameter (2mm/2m), light reflexes (+/+), no paralysis B

A M

P L
E

at home

Secondary survey
Head/Neck
Eye : anemic conjunctivae (-/-), icteric sclera (-/-) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)

Chest

I : symmetric respiratory movement, retraction (-) P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen
Extremities

I : wound (-), distension (-), hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

See local status

Clinical Picture

Laboratory Finding
Hb L E Ht Plt Ur Cr : : : : : : : 12,3 g/dl 6,3 ribu /ul 4,72 x 106/ul 30,8 vol% 362.000/ul 49 mg/dl 1.3 mg/dl

Glucose : 112 mg/dl PT : 11.7 mg/dl APTT : 23.9 mg/dl Na/K/Cl: 140.9/4.4/78

X-Ray

Working Diagnosis
Vulnus ictum et regio hemithorax dextra

Management
IvFd rl 20 dpm Inj Ranitin 2x1 amp Inj Ketorolac 2x1 amp Inj Ceftriaxone 2x1 gr Ro/ thorax/ 6 jam