Emergency Report 23-24

Emergency Report
October 23th 24th 2014
Resident on Duty : dr Yan Aditya

Chief : Iqbal
Coass on duty: Novita, Sindhu, Sari, Athira,
Aditya, Riza, Ririn
PATIENT LIST
Minor surgery
Oncology surgery
Digestive surgery
:3
Thorax cardiovascular surgery
Plastic surgery
Urology surgery
Neurosurgery
:2
Pediatric surgery
Orthopedic
:4
Total
:9
Patients List
No
Identity
Admission to
E.R.
Diagnosis
stroke hemorrhage
Mrs.Suratin October
23rd 2014/at
with ICH e/r
/64 y.o/
temporoparietal
1.12.52.82 15.00
dextra 35 cc +
IVH +
hidrosephalus
acute
Management
Observation of vital sign

Head up 30
O2 10 lpm
IVFD NS 20 gpm
Ranitidin 2x1
Ketorolac 3x30 mg
Manitol 4x150 cc
Consult to Neurology Surgeon:
- Craniotomy evacuation (cito)
Patients List
No
Identity
Admission to
E.R.
Diagnosis
Stroke
Mrs.Norsya October
m/47 y.o/ 23rd 2014/at Hemorrhage with
ICH at parietal
1.12.52.85 15.40
sinistra (22,5 cc) +
Management

Head up 30
O2 10 lpm
IVFD NS 20 gpm
Ranitidin 2x1
Ketorolac 3x30 mg
Manitol 4x150 cc
Consult to Neurology Surgeon:
- Craniotomy evacuation
Patients List
No
Identity
Admission to
E.R.
Diagnosis
23rd October Open fracture of

Mr.
Chelsio/1.12 2014/17.40 digiti 5 phalang
distal
.52.93/19 yo WITA
Vulnus laceratum
and escoriatum
e/r dorsum manus
dextra
Management
-Vital Sign observation

-IVFD RL 20gtm
-Antibiotic
-ATS
-Analgesic
-H2 Blocker
-Consult to Orthopedic
Surgeon
-Hospitalized
-Pro cito debridement + ORIF
wire
Patients List
No
Identity
Admission to
E.R.
Matnor/ 11 23rd
yo/1.12.58.5 October
2014/ 19.00
7
Diagnosis
Mild Head Injury

(GCS 14)
Closed fracture of
tibia fibula dextra
1/3 distal
tranverse
displacment
Closed fracture of
radius ulna sinistra
1/3 medial
trranverse
displacement
Closed fracture of
angulus
mandibula dextra
Management
Observation Vital Sign

Antibiotic
Analgesic
H2 Blocker
O2
X-ray cervical skull,
antebrachii, cruris
Consult to pllastic surgeon
ORIF elective
Consult to orthopedic surgeon
ORIF elective
Patients List
No
Identity
Mr.
Ardiansyah/
1.12.53.05/
19 yo
Admission to
E.R.
Diagnosis
Management
23rd October Closed fracture of

2014/ 21.00 femur sinistra 1/3

-Antibiotic
medial transversal -Analgesic
displacement
-H2 Blocker
Open fracture of
patela sinistra
-Consult to Orthopaedic
Fracture condillus
Surgeon
mandibula
-Hospitalized
bilateral
-ORIF elective
-Skin traction
-Consult to plastic surgery

-Orif elective
Patients List
No
Identity
Admission to
E.R.
23rd
Mr.
Yusri/1.12.5 October
2014/ 22.30
3.04/25 yo
Diagnosis
Close fracture of
femur sinistra 1/3
medial
comminutive
displacement
Management

-Antibiotic
-Analgesic
-H2 Blocker
-Consult to Orthopaedic
Surgeon
-Skin traction
-Hospitalized
-ORIF elective
Patients List
No
Identity
Admission to
E.R.
23th
Mrs.
Mahsunah October
2014/ 23.30
/24
yo/1.12.53.
15
Diagnosis
Ileus obstructive
partial et causa
susp. Adhesive
post op.
Management
-Vital sign observation

-IVFD RL 250 cc/day
-Antibiotic
-H2 blocker
-Analgesic
Consult to digestive surgeon :
Hospitalized
Fleet enema
Patients List
No
Identity
Mr.
Ridwan/1.1
2.53.14/37
yo
Admission to
E.R.
24th
October
2014/ 02.00
Diagnosis
Mild head injury

Fracture of
simfisis
mandibulla
Internal bleeding
ec Abdomen
blunt trauma
Management

-Head up 30 degree
-O2 4 lpm canulle nasal
-NS 20 gpm
-Antibiotic
-Analgesic
-H2 Blocker
-Tranexamat acid 3x500
-X-ray trauma series
-Complete blood count
Consult to digestive Surgeon
Pro cito laparotomy
Consult to plastic Surgeon
Pro ORIF elective
Patients List
No
Identity
Mr.
Ridwan/1.1
2.53.14/37
yo
Admission to
E.R.
24th
October
2014/ 02.00
Diagnosis
Mild head injury

Fracture of
simfisis
mandibulla
Peritonitis due to
Internal bleeding
ec Abdomen
blunt trauma
Management

-Head up 30 degree
-O2 4 lpm canulle nasal
-NS 20 gpm
-Antibiotic
-Analgesic
-H2 Blocker
-Tranexamat acid 3x500
-NGT
-DC
-X-ray trauma series
-Consult to nuero Surgery

-Pro CT scan
Consult to digestive Surgeon
Patients List
No
Identity
Admission to
E.R.
Diagnosis
Peritonitis difuse
Mr. Suroto/ 24th
due to acute
yo/1.12.53. October
2014/ 05.00 mesenterial
15
trombotic
Management
-Vital sign observation

-IVFD RL 20 gpm
-Antibiotic
-H2 blocker
-BNO 3 position
-Urinnalysa
-NGT
-DC
Consult to digestive surgeon :
Pro laparotomy cito
1. Mrs.Suratin/64 y.o/ October 23rd 2014

1.12.52.82/at 15.00
Chief Complain : decrease of consciousness
Since 5 days ago, patient suddenly get faint
when she doing her daily activity. She woke
up, patient complain about vertigo and
vomiting for several times. She feel weakness
on her body. History of HT (+) more than 10
years. She then brought to the Pulang Pisau
hospital and sent to Dorys hospital for CT
scan. After CT scan, she was reffered to Ulin
hospital for the advance therapy.
Physical Examination
Vital sign :
BP= 240/110 mmhg
HR = 96times/minute
RR = 22 times/minute
BT = 37C
Head/Neck
Chest
Abdomen
Extremities
Head : Normochepal
Eyes : anemic conjunctivae(-/-), icteric sclerae (-/-)
Mouth : Moist mucous membrane
Neck : lymph nodes enlargement (-), JVP
enhancement (+)
I : symmetric respiratory movement, no retraction

P : symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, no rhonchi, no wheezing,
crackles (-)
I : excoriation (-)
P : H/L/M = no palpable, tenderness (-), rebound
tenderness (-), muscular rigidity (-)
P : tympanic
A : normal bowel sound
Warm (+), no edema, no paralysis.
Clinical picture
Head CT Scan, October 24th 2014
Laboratory (23rd Oct 2014)

Haemoglobin
WBC
Erythrocyte
Hematocrit
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
13,6
11,0
4,80
41,5
242
13,7
86,6
28,3
32,7
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%

HASIL
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
78,4
13,8
7,8
8,60
1,5
0,9
NILAI
NORMAL
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
SATUAN
%
%
%
ribu/ul
ribu/ul
ribu/ul
Natrium
Kalium
Chloride
HASIL
NILAI
NORMAL
SATUAN
142,2
3,9
105,3
135-146
3,4-5,4
95-100
mmol/l
mmol/l
mmol/l
PT
9,2
APTT
11,4
Blood glucose
149
<200
mg/dl
SGOT
26
0-46
U/I
SGPT
21
0-45
U/I
3,5-5,5
Ureum
66
10-50
mg/dl
Creatinine
1,1
0,7-1,4
mg/dl
2,4-5,7
Working Diagnosis
stroke hemorrhage + ICH e/r temporoparietal
dextra 35 cc + IVH + hidrosephalus acute
Management
Head up 30
O2 10lpm nasal
IVFD NS
Ranitidin 2x1
Ketorolac 3x30 mg
Manitol 4x150 cc
Consult to Neurology
Surgeon:
- Craniotomy evacuation
(cito)
BACK
2. Mrs.Norsyam/47 y.o/ October 23rd 2014

1.12.52.85/at 15.40
Chief Complain : Weakness on the right
extremities
Since 1 week before admission,she got faint
when did her daily activity. When she woke up,
she vomited once and fell weakness at all her
right extremities and cannot speak well. She then
hospitalized at Islam hospital and got CT Scan,
then referred brought to Ulin hospital. History of
hipertension (+) for 5 years , history of diabetic
unknown.
Physical Examination
Vital sign :
BP= 160/110 mmhg
HR = 72times/minute
RR = 22 times/minute
BT = 37C
Head/Neck
Chest
Abdomen
Extremities
Head : Normochepal
Eyes : anemic conjunctivae(-/-), icteric sclerae (-/-)
Mouth : Moist mucous membrane
Neck : lymph nodes enlargement (-), JVP
enhancement (+)
I : symmetric respiratory movement, no retraction

P : symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, no rhonchi, no wheezing,
crackles (-)
I : excoriation (-)
P : H/L/M = no palpable, tenderness (-), rebound
tenderness (-), muscular rigidity (-)
P : tympanic
A : normal bowel sound
Warm (+), no edema, no paralysis.
Clinical picture
CT Scan October 23rd 2014

Haemoglobin
WBC
Erythrocyte
Hematocrit
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
11,3
8,1
4,61
35,4
232
13,4
76,9
24,5
31,9
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%

HASIL
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
68,6
20,8
10,6
5,60
1,7
0,8
NILAI
NORMAL
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
SATUAN
%
%
%
ribu/ul
ribu/ul
ribu/ul
Natrium
Kalium
Chloride
HASIL
NILAI
NORMAL
SATUAN
139,0
4,2
101,2
135-146
3,4-5,4
95-100
mmol/l
mmol/l
mmol/l
PT
10,1
APTT
23,9
Blood glucose
75
<200
mg/dl
SGOT
28
0-46
U/I
SGPT
16
0-45
U/I
Albumin
4,0
3,5-5,5
Ureum
30
10-50
mg/dl
Creatinine
0,6
0,7-1,4
mg/dl
Uric Acid
2,4
2,4-5,7
Working Diagnosis
SH+ ICH at parietal sinistra (22,5 cc)
Management
Observation of vital
sign
Head up 300
O2 4lpm nasal
Manitol 4x100 cc
Ranitidin 2x1
Ketorolac 3x30 mg
Consult to Neurology
Surgeon:
- Craniotomy
evacuation (cito)
BACK
3. Mr. Chelsio/1.12.52.93/19 yo/23rd October

2014/17.40 WITA
Chief complain: Open wound on the right hand
Half an hour before admission when patient at the
firefighter car, the car rolled because avoiding a bus,
after crash the car roll over. The window didnt close and
his hand wedge on the window and suppressed by car.
Faint (-), nose/mouth/ear bleeding (-), he got bleeding
from his finger and its pain to move, then he brought to
the ULIN hospital by his friends.
Primary Survey
Clear (+), snoring (-), gurgling(-), c-spine control
Clear, RR : 20 x/mt, symmetric respiratory movement,

VBS equal
BP: 110/80 mmHg, Pulse 82 x/mnt ,reguler, strong

pulsation.
GCS 15 E4V5M6, Pupil equal 3mm/3mm, no paresis, Brille

Haematoma -/-, Bloody Rinorrhae -/-, Bloody Otorrhae -/-,
Battles sign -/-
(-)
(-)
(-)
2 Hours before admission
On the street
Secondary Survey
Head/Neck
Eyes : anemic conjunctivae (-/-), icteric sclerae (-),

Nose : epistaxis (-)
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
Chest
I : symmetric respiratory movement,

P : symmetric VF (+/+)
P : sonor at all lung
A : symmetric VBS +/+, rhonchi (-/-), wheezing (-/-)
Abdomen
Extremities
I : distended (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass palpable,
tenderness (-) , rebound tenderness (-)
P : Tympanic
No parese, no oedem, scars (-),
Secondary Survey
Et regio manus
dextra (digiti 5)
L
F
M
: Open wound at 5th finger with bone exposed

: Pressure pain (+), crepitation.(+)
: ROM limited cause of pain
Et regio
dorsum manus
dextra
L
F
M
: Open wound muscle based about 10 cm

: Crepitation (-)
: ROM normal
Clinical Picture
Clinical Picture
Et regio manus dextra (digiti 5)
L
F
M
: Open wound at 5th finger with bone

exposed
: ROM limited cause of pain
Clinical Picture
Et regio dorsum manus dextra
L
F
M
: Open wound soft tissue based

about 10 x 1 cm, escoriation (+)
: Crepitation (-)
: ROM normal
X-Ray 23rd October 2014

Haemoglobin
WBC
Erythrocyte
Hematocrit
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
12,8
7,4
4,63
40,1
180
14,0
86,7
27,6
31,9
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
HASIL
NILAI
NORMAL
SATUAN
56,1
35,7
8,2
4,20
2,6
0,6
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
%
%
%
ribu/ul
ribu/ul
ribu/ul
Natrium
Kalium
Chloride
HASIL
NILAI
NORMAL
SATUAN
138,3
3,9
100,8
135-146
3,4-5,4
95-100
mmol/l
mmol/l
mmol/l
PT
11,7
APTT
28,1
Blood glucose
101
<200
mg/dl
SGOT
38
0-46
U/I
SGPT
35
0-45
U/I
3,5-5,5
Ureum
68
10-50
mg/dl
Creatinine
1,0
0,7-1,4
mg/dl
2,4-5,7
Working Diagnosis
Open fracture of digiti 5 phalang distal
Vulnus laceratum and escoriatum e/r dorsum manus dextra
Management
- Vital Sign
observation
- IVFD RL 20gtm
- Antibiotic
- Analgesic
- ATS
- H2 Blocker
- Consult to
Orthopedic Surgeon
- Hospitalized
- Pro cito debridement
+ ORIF wire
BACK
4. Matnor/ 11 yo/1.12.58.57/ 23rd October 2014/

19.00
Chief complaint: Pain on the arms and legs
3 hours before admission, patient hit by motorcycle at
handil bakti when he cross the road. He hit by the
motorcycle from the right side. He threw far about 1
meter. Hystory of faint (+) . Theres no history of
nose/mouth/ear bleeding, after woke from his faint
patient feel very pain at his arms and legs, and cannot
walk. He then brought by people to the emergency unit at
Anshari Saleh hospital and get simple fixation for his
arm and leg, after that she referenced to Ulin hospital for
further therapy.
Primary Survey
Clear, RR : 22x/mt, symmetric respiratory movement,

VBS equal, Rh(-/-), Wh (-/-)
Pulse 85 x/mnt ,reguler, strong pulsation.

Battles sign -/-
(-)
(-)
(-)
2 hours before admission
On the road
Secondary Survey
Head/Neck

Mouth : wet mucosa
Chest

Abdomen
I : distended (-). Et regio pelvic lesion (-)

P : Liver/spleen/kidney not palpable
P : Tympanic
Extremities
No parese, no oedem,
Secondary Survey
Et regio
mandibula
dextra
L
F
M
: deform (+), swelling (+)

: Crepitation (+), Pressure pain (+)
: ROM limited because of pain
Et regio
antebrachii
sinistra
L
F
M

: crepitation (+), Pressure pain (+), A. Radialis pulse (+)
Et regio
cruris dextra
L
F
M

: Pressure pain (+), crepitation (+), A. dorsalis pedis (+)
: False movement (+)
Clinical
Picture
Status localize
Et regio mandibula dextra
L
F
M
: deform (+), swelling (+), sutured wound 3cm lenght

: Crepitation (+), Pressure pain (+)
Status localize
Et regio antebrachii
sinistra
L
: deform (+), swelling
(+)
F
: crepitation (+),
Pressure pain (+), A. Radialis
pulse (+)
M
: ROM limited because
of pain
Status localize
Et regio cruris dextra
L
F
: Pressure pain (+),
crepitation (+), A. dorsalis
pedis (+)
M
: False movement (+)
X Ray October 23rd 2014
CT Scan October 23rd 2014

Haemoglobin
WBC
Erythrocyte
Hematocrit
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
9,8
24,3
4,03
30,9
381
13,5
76,8
24,3
31,7
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%

HASIL
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
85,8
8,8
5,4
20,90
2,1
1,3
NILAI
NORMAL
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
SATUAN
%
%
%
ribu/ul
ribu/ul
ribu/ul
Laboratory October 23rd 2014

HASIL
NILAI
NORMAL
SATUAN
PT
12,6
APTT
28,4
Blood glucose
249
<200
mg/dl
SGOT
145
0-46
U/I
SGPT
48
0-45
U/I
3,5-5,5
Ureum
35
10-50
mg/dl
Creatinine
0,7
0,7-1,4
mg/dl
Working Diagnosis
Mild Head Injury (GCS 14)
Closed fracture of tibia fibula dextra 1/3 distal tranverse
displacment
Closed fracture of radius ulna sinistra 1/3 medial tranverse
displacement
Closed fracture angulus mandibula dekstra
Management
Observation Vital
Sign
Antibiotic
Analgesic
H2 Blocker
Oxygenation
X-ray cervical
skull,
antebrachii,
cruris
Consult to plastic
surgeon
ORIF elective
Consult to
orthopedic
surgeon
ORIF elective
BACK
5. Mr. Ardiansyah/1.12.53.05/19 yo/23rd October 2014/

21.00
Chief complain: Pain and wound at the left leg
3 hours before admission patient had a crash with a
motorcycle from the opposite direction in martapura. He
wore Helmet (+), he fall and his leg was hit by
motorcycle. Faint (+), nose/eye/mouth bleeding (-). He
feel pain on the leg, bleeding and pain when it be moved.
He also feel pain on his jaw. And his jaw cant be close
well He then brought to the Martapura hospital and
referenced to Ulin hospital.
Primary Survey

VBS equal

pulsation.

Battles sign -/-
(-)
ATS
(-)
On the street
Secondary Survey
Head/Neck

Mouth : wet mucosa
Chest

Abdomen
Extremities
I : distended (-)
P : Tympanic
No parese, no oedem, scars (-),
Secondary Survey
Et regio
Mandibula
dextra sinistra
L
F
M
: Deform (+)
: ROM mandibula limited
Et regio femur
sinistra
L
F
M
: Sutured wound (+) about 1 cm

: Crepitation (+), Pressure pain (+), A.dorsalis pedis (+)
: False movement (+), ROM limited (+)
Et genu tibia
sinistra
L
F
M
: Sutured wound 10 cm
: Crepitation (+), pressure pain (+), A.Dorsalis pedis (+)
: False movement (-), ROM limited d
Clinical Picture
Clinical Picture
Et regio mandibula
L
: Deform (+), mal
oclusion (+)
F
: Pressure pain (+),
crepitation.(+)
M
: ROM mandibula
limited
Et regio femur sinistra
L
: Sutured wound (+) about 1 cm
F
: Crepitation (+), Pressure pain
(+), A.dorsalis pedis (+)
M
: False movement (+), ROM
limited (+)
Clinical
Picture
Clinical
Picture
Et regio genue sinistra
L
: Sutured wound 10 cm
F
: Crepitation (+),
pressure pain (+), A.Dorsalis
pedis (+)
M
: False movement (-),
ROM limited

Haemoglobin
WBC
Erythrocyte
Hematocrit
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
9,2
16,0
3,26
29,1
233
13,5
89,4
28,2
31,6
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
HASIL
NILAI
NORMAL
SATUAN
76,0
16,7
7,3
12,20
2,7
1,1
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
%
%
%
ribu/ul
ribu/ul
ribu/ul

HASIL
NILAI
NORMAL
SATUAN
INR
1,02
PT
11,6
APTT
24,5
Blood glucose
192
<200
mg/dl
SGOT
71
0-46
U/I
SGPT
34
0-45
U/I
Albumin
3,5-5,5
Ureum
23
10-50
mg/dl
Creatinine
0,9
0,7-1,4
mg/dl
Working Diagnosis
Closed fracture of femur sinistra 1/3 medial transversal
displacement
Open fracture pattela sinistra
Fracture condillus mandibula bilateral
Management
- Vital Sign
observation
- Antibiotic
- Analgesic
- H2 Blocker
- Consult to
Orthopaedic
Surgeon
- Hospitalized
- debrideman
- ORIF elective
BACK
6. Mr. Yusri/1.12.53.04/25 yo/23rd October 2014/

22.30
Chief complain: Pain on the left leg
1 day before admission patient had been fallen when he
ride motorcycle. His motorcycle crashed the tree and he
fall with the left leg hit ground first. Helmet (+). Faint (), nose/mouth/ear bleeding (-). After that accident, he
feel his pain on his leg and its pain to be move. Then, he
took to Tanah Bumbu hospital by friends. He did x-ray
photo and got medication. Patient referenced to Ulin
hospital for advance therapy.
Primary Survey

VBS equal

pulsation.

Battles sign -/-
(-)
Ranitidin, ketorolac
(-)
On the street
Secondary Survey
Head/Neck
Chest
Abdomen
Extremities
Et Regio femur
sinistra

Mouth : wet mucosa

I : distention (-)
P : Tympanic
No parese, no oedem, scars

L : Deform (+), swelling (+)
F : crepitation (+), Pressure pain (+), a.dorsalis pedis (+)
M : ROM limited because of pain, false movement (+)
Clinical Picture
Clinical Picture
Et Regio femur sinistra
L : Deform (+), swelling (+)
F : crepitation (+), Pressure pain (+), a.dorsalis pedis (+)
M : ROM limited because of pain, false movement (+)
X-Ray 22nd October 2014 (At tanah bumbu

hospital)
X-Ray 22nd October 2014 (At tanah bumbu

hospital)

Haemoglobin
WBC
Erythrocyte
Hematocrite
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
11,9
9,5
4,62
37,7
150
13,6
81,8
25,7
31,5
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
HASIL
NILAI
NORMAL
SATUAN
78,3
13,6
8,1
7,40
1,3
0,8
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
%
%
%
ribu/ul
ribu/ul
ribu/ul

HASIL
NILAI
NORMAL
SATUAN
136,8
3,6
102,0
135-146
3,4-5,4
95-100
mmol/l
mmol/l
mmol/l
PT
11,3
9,9-13,5
APTT
25,9
22,2-37,0
Blood glucose
140
<200
mg/dl
SGOT
54
0-46
U/I
SGPT
30
0-45
U/I
Natrium
Kalium
Chloride
3,5-5,5
Ureum
12
10-50
mg/dl
Creatinine
0,5
0,7-1,4
mg/dl
2,4-5,7
Working Diagnosis
Close fracture of femur sinistra 1/3 medial comminutive
displacement
Management
- Vital Sign
observation
- Analgesic
- H2 Blocker
- Consult to
Orthopaedic
Surgeon
- Skin traction
- Hospitalized
- ORIF elective
BACK
7. Mrs. Mahsunah /24 yo/1.12.53.15/23th October

2014/ 23.30
Chief complain: distention stomach
One day before admission patient feel her stomach
distended and she cant defecated but stil fart. Vomit (+),
4 days before admission she has a history of caesarean
section surgery because of fetal distress at Martapura
hospital. After that surgery she cant defecate but still
fart. When she was at her 6 months pregnancy, she
diagnosed had appendicitis. Theres no history bloody
feces before. History of watery feces 2 days before
admission, but he didnt take any medication and then
she brought to Ulin hospital because of her complain.
Vital Sign
GCS
TD
HR
RR
Temp
: E4V5M6
: 120/70 mmHg
: 84 times/minutes
: 20 times/minutes
: 36,6 C
General Examination
Head/Neck

Mouth : wet mucosa
Chest
I : symmetric respiratory movement, retraction (-)

Abdomen
Extremities
I : distention (+). Wound of SC surgery (+), clean and sutured,

pus (-)
A : metallic sound (+), bowel sound (+)
P : Liver/spleen/kidney not palpable
P : Tympanic
Warm (+), No parese, no oedem, scars (-)
Rectal touche
Spincter Ani Tone : strong

Collapse ampulla (-)
Pressure pain (-)
Massa (-)
Feces (+), blood (-)
Clinical Picture
Status localize
Abdomen : distention
(+). Wound of SC surgery
(+), clean and sutured,
pus (-)
Auscultation : metallic sound (+),
X-ray (BNO 3 positions) 24th October 2014
Laboratory (24th Oct 2014)

Haemoglobin
WBC
Erythrocyte
Hematocrit
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
8,0
15,7
3,40
27
351
17,3
79,5
23,5
29,6
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
Result
81,9
10,9
7,2
12,90
1,7
1,1
Normal score
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
Unit
%
%
%
ribu/ul
ribu/ul
ribu/ul
Laboratory October 24th 2014

HASIL
NILAI
NORMAL
SATUAN
132,8
3,6
103,5
135-146
3,4-5,4
95-100
mmol/l
mmol/l
mmol/l
PT
9,7
9,9-13,5
APTT
26,1
22,2-37,0
Blood glucose
113
<200
mg/dl
SGOT
28
0-46
U/I
SGPT
11
0-45
U/I
Ureum
24
10-50
mg/dl
Creatinine
0,6
0,7-1,4
mg/dl
Natrium
Kalium
Chloride
Working Diagnosis
Ileus obstructive partial et causa susp. Adhesive post op.
Management
- Vital sign
observation
- IVFD RL
Antibiotic
- H2 blocker
- Analgesic
Consult to
digestive
surgeon :
Hospitalized
Fleet enema
BACK
8. Mr. Ridwan/1.12.53.14/37 yo/24th October 2014/

02.00
Chief complain: abdominal pain
1 hours before admission patient ride a motorcycle while
drunk. He didnt use helmet and crash an street devider
around Banjarbaru. Mechanism of trauma is unknown.
and got faint, nose/mouth/ear bleeding (+/+/-), and his
jaw are broken. he was brought to Banjarbaru hospital by
civilian and then referenced to Ulin hospital. After he
woke up. He feel his stomach pain
Primary Survey

VBS equal

pulsation.

Haematoma (+), Light reflex +/+
(-)
(-)
(-)
On the street
General Examination
Head/Neck

Nose : epistaxis (+)
Mouth : deformity at lower jaw (+) mal oklusion (+)
Chest

Abdomen
I : distention (-).
A : metallic sound (-), bowel sound (+) decreased
P : Liver/spleen/kidney not palpable, tenderness (+)
P : Tympanic
Extremities
Rectal touche
Normal Spincter ani tone

Collapse ampulla(-)
Mass (-)
Pressure pain (+)
Clinical Picture
Clinical Picture
Et regio periorbita
Brill haematome +/+
Et regio mandibula
L
:Deform (+),
F
: Crepitation (+), step
defect (+)
M
: False movement (+),
ROM limited (+)
X-Ray 24th October 2014

Haemoglobin
WBC
Erythrocyte
Hematocrit
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
9,4
16,6
2,88
27,1
259
15,0
94,4
32,6
34,6
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
HASIL
NILAI
NORMAL
SATUAN
68,9
13,7
17,4
11,40
2,3
2,9
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
%
%
%
ribu/ul
ribu/ul
ribu/ul

HASIL
NILAI
NORMAL
SATUAN
144,6
4,2
108
135-146
3,4-5,4
95-100
mmol/l
mmol/l
mmol/l
PT
13,3
9,9-13,5
APTT
25,3
22,2-37,0
Blood glucose
133
<200
mg/dl
SGOT
625
0-46
U/I
SGPT
375
0-45
U/I
Ureum
31
10-50
mg/dl
Creatinine
1,5
0,7-1,4
mg/dl
Natrium
Kalium
Chloride
Working Diagnosis
Mild head injury
Fracture of simfisis mandibulla
Peritonitis due to Internal bleeding ec Abdomen blunt trauma
Management
-
Vital Sign observation

Head up 30 degree
O2 4 lpm canulle nasal
NS 20 gpm
Antibiotic
Analgesic
H2 Blocker
Tranexamat acid 3x500
NGT
DC
X-ray trauma series
Complete blood count
- Consult to nuero
Surgery
- Pro CT scan
- Consult to digestive
Surgeon
- Pro cito laparotomy
- Consult to plastic
Surgeon
- Pro ORIF elective
BACK
9. Mr. Suroto/ yo/1.12.53.15/24th October 2014/

05.00
Chief complain: Cant defecate
1 day before admission patient complain that he cant
defecate and fart, his stomach distention and pain,
theres no history of watery feces or bloody feces. Patien
also complain vomiting after he take a meal. The pain
start since 3 days ago arround umbilical and than spread
to whole abdominal. The pain getting worst each day
especialy after eat. No history of herbal or analgetic
daily compsumption before. No history of loss body
weight. No hystory of fever. Hystory of HT (+)more than
5 years hystory of DM is unknown
Vital Sign
GCS
TD
HR
RR
Temp
: E4V5M6
: 160/100 mmHg
: 90 times/minutes
: 20 times/minutes
: 37 C
General Examination
Head/Neck
Head : Normochepal
Mouth : wet mucosa
Chest

Abdomen
Extremities
I : distention (-).
A : bowel sound (+)
P : Liver/spleen/kidney not palpable. Pressure pain (+),
rebound tenderness (+)
P: Tympanic
Rectal touche
Spincter Ani Tone : strong

Smooth mucosa
Collapse ampulla (-)
Pressure pain (+) at 9-3 oclock
Massa (-)
Clinical Picture
Status localize
Abdomen
I : distention (+).
A : bowel sound (+) decreased
P : Liver/spleen/kidney not
palpable. Pressure pain (+),
rebound tenderness (+)
P: Tympanic
X Ray 24th October 2014
X Ray 24th October 2014

Haemoglobin
WBC
Erythrocyte
Hematocrit
Platelet
RDW-CV
MCV
MCH
MCHC
Hasil
18,0
19,2
6,10
52
263
13,4
85,3
29,5
34,6
Nilai Normal
14,0-18,0
4,0-10,5
3,90-5,50
42,00-52,00
150-450
11,5-14,7
80,0-97,0
27,0-32,0
32,0-38,0
Satuan
g/dl
Ribu/Ul
Juta/Ul
Vol%
Ribu/Ul
%
Fl
Pg
%
Gran%
Limfosit%
MID%
Gran#
Limfosit#
MID#
Result
84,7
9,7
5,6
16,30
1,9
1
Normal score
50,0-70,0
25,0-40,0
4,0-11,0
2,50-7,00
1,25-4,0
Unit
%
%
%
ribu/ul
ribu/ul
ribu/ul
Natrium
Kalium
Chloride
Blood glucose
SGOT
SGPT
Ureum
Creatinine
HASIL
NILAI
NORMAL
SATUAN
137,5
135-146
3,4-5,4
95-100
mmol/l
mmol/l
mmol/l
311
33
23
<200
mg/dl
0-46
U/I
0-45
U/I
34
0,9
10-50
mg/dl
0,7-1,4
mg/dl
3,5
101,9
Urinalisa (October 24th 2014)

HASIL
NILAI
NORMAL
Yellowish-clear
Yellowish-clear
5.0
5,0-6,5
Negative
Negative
Trace
Negative
Glucose
4+
Negative
Bilirubin
Negative
Negative
Blood smear
Negative
Negative
Nitrit
Negative
Negative
0,2
0.1-1.0
Negative
Negative
Color
pH
Keton
Protein-albumin
Urobilinogen
WBC
SATUAN
Urinalisa (October 24th 2014)

HASIL
WBC
Eritrocyte
Cilinder
Epitel
Bacteri
Kristal
Lain-lain
0-1
0-1
Negative
1+
Negative
Negative
Negative
NILAI
NORMAL
0-3
0-2
Negative
1+
Negative
Negative
Negative
SATUAN
Working Diagnosis
. Peritonitis difuse due to acute mesenterial trombotic
Management
- Vital sign
observation
- IVFD RL 20 gpm
- Antibiotic
- H2 blocker
- BNO 3 position
- Complete blood
count
- Urinnalysa
- NGT
- DC
Consult to
digestive
surgeon :
Pro laparotomy
cito
BACK
THANKS!

Emergency Report 23-24

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Emergency Report 23-24

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Emergency Report

October 23th 24th 2014

Resident on Duty : dr Yan Aditya

Thorax cardiovascular surgery

Observation of vital sign

Observation of vital sign

23rd October Open fracture of

-Vital Sign observation

Mild Head Injury

Observation Vital Sign

23rd October Closed fracture of

-Vital Sign observation

-Consult to plastic surgery

-Vital Sign observation

-Vital sign observation

Mild head injury

-Vital Sign observation

Mild head injury

-Vital Sign observation

-Consult to nuero Surgery

-Vital sign observation

1. Mrs.Suratin/64 y.o/ October 23rd 2014

I : symmetric respiratory movement, no retraction

Warm (+), no edema, no paralysis.

Head CT Scan, October 24th 2014

Laboratory (23rd Oct 2014)

Laboratory (23rd Oct 2014)

Laboratory (23rd Oct 2014)

2. Mrs.Norsyam/47 y.o/ October 23rd 2014

I : symmetric respiratory movement, no retraction

Warm (+), no edema, no paralysis.

CT Scan October 23rd 2014

Laboratory (23rd Oct 2014)

Laboratory (23rd Oct 2014)

Laboratory (23rd Oct 2014)

3. Mr. Chelsio/1.12.52.93/19 yo/23rd October

Clear (+), snoring (-), gurgling(-), c-spine control

Clear, RR : 20 x/mt, symmetric respiratory movement,

BP: 110/80 mmHg, Pulse 82 x/mnt ,reguler, strong

GCS 15 E4V5M6, Pupil equal 3mm/3mm, no paresis, Brille

2 Hours before admission

Eyes : anemic conjunctivae (-/-), icteric sclerae (-),

I : symmetric respiratory movement,

No parese, no oedem, scars (-),

: Open wound at 5th finger with bone exposed

: Open wound muscle based about 10 cm

: Open wound at 5th finger with bone

: Open wound soft tissue based

X-Ray 23rd October 2014

Laboratory (23rd Oct 2014)

Laboratory (23rd Oct 2014)

Laboratory (23rd Oct 2014)

4. Matnor/ 11 yo/1.12.58.57/ 23rd October 2014/

Clear (+), snoring (-), gurgling(-), c-spine control

Clear, RR : 22x/mt, symmetric respiratory movement,

Pulse 85 x/mnt ,reguler, strong pulsation.

GCS 14 E3V5M6, Pupil equal 2mm/2mm, no paresis, Brille

2 hours before admission

Eyes : anemic conjunctivae (-/-), icteric sclerae (-),

I : symmetric respiratory movement,

I : distended (-). Et regio pelvic lesion (-)

: deform (+), swelling (+)

: deform (+), swelling (+)

: deform (+), swelling (+)