Emergency Report

Dec 27th-28th 2015

Resident on duty:
dr. Kiki Budiani

General Surgery

Digestive Surgery

Thorax Cardiovascular Surgery :

Plastic Surgery

Urology Surgery

Neuro Surgery

Pediatric Surgery

Total

:
:

4
:

Oncology Surgery
Orthopaedy

Patient List
No
1.

Identity
Mr. Masrani/ 58
y.o /
1.19.40.09/10.00
am

Admission
to ER
Dec 27 th ,
2015

Diagnose
HIL dextra
incarcerated

Treatment
VS obs
IVFD RL 20 tpm
NGT& DC
Antibiotic
Analgetic
H2 blocker
Thorax Xray
Complete blood
count
Co. To Digestive
surgery
Plan to
Herniorrhapy

Patient List
No

Identity

2.

Mr. Lamrah/ 64 y.o

/1.19.40.15/12.00
am

Admission
to ER
Dec 27 th ,
2015

Diagnose
Ca.Mammae Dx
T4cN1Mx Karnofsky
score 40+ Anemia
+ Electrolite
imbalance

Treatment
VS obs
IVFD NS 20 tpm
Antibiotic
Analgetic
H2 blocker
Thorax Xray
Complete blood
count
Blood Transfusion
Co. To Oncology
surgery
USG Hepar
Check IHC

Patient List
No

Identity

3.

Mrs. Siti Habibah/

59 y.o /
1.19.40.13/11.30
am

Admission
to ER
Dec 27 th ,
2015

Diagnose
Open Fracture Right
End Radius distal +
Closed Fracture
Right Neck femur

Treatment
VS obs
IVFD RL 20 tpm
Antibiotic
Analgetic
H2 blocker
Thorax Xray
Complete blood
count
Hip xray,
Antebrachii xray
Admitted to Aster
Co. To Orthopaedi:
ORIF Elective and
Arthroplasty

Patient List
No

Identity

4.

Mr. M. Marzuki/ 57
y.o /
1.19.40.24/11.00
pm

Admission
to ER
Dec 27th ,
2015

Diagnose
Severe Head Injury
+ IVH + SDH at left
temporal

Treatment
VS Obs + GCS
O2 + Head Up 30
IVFD NS
Antibiotic
Analgetic
H2 Blocker
Complete blood
count
Skull Xray, Thorax
xray
Head Ct scan
Patient discharged
by request

Patient List
No
5.

Identity
Mr. Wayan
Sudarte/ 36 y.o /
1.19.40.32/05.00
pm

Admission
to ER
Dec 27 th ,
2015

Diagnose
Mild Head Injury +
Contusio cerebri at
left frontal

Treatment
VS Obs + GCS
O2 + Head Up 30
IVFD NS
Analgetic
H2 Blocker
Complete blood
count
Skull Xray, Thorax
xray
Head Ct scan
Co. To.
Neurosurgery :
conservative

Patient List
No
6.

Identity
Mr. Kaliani/ 24
y.o /
1.19.40.05/08.00
am

Admission
to ER
Dec 27 th ,
2015

Diagnose
Traumatic
amputation at Left
elbow + Multiple
Vulnus scissum at
right shoulder, left
shoulder, left back,
head

Treatment
VS Obs + GCS
O2
IVFD RL
Antibiotic
Analgetic
H2 Blocker
Complete blood
count
Skull Xray, Thorax
xray
Patient discharged
by request

Patient List
No
7.

Identity
Mr. Muhammad
Nuryasin/ 27 y.o /
1.19.40.43/11.00
pm

Admission
to ER
Dec 27 th ,
2015

Diagnose
Mild Head Injury

Treatment
VS Obs + GCS
O2 + Head Up 30
IVFD NS
Analgetic
H2 Blocker
Complete blood
count
Skull Xray, Thorax
xray
Head Ct scan
Co. To.
Neurosurgery :
Conservative

Patient List
No

Identity

8.

Mr. Nadjamuddin/
66 y.o /
1.19.40.36/11.30
pm

Admission
to ER
Dec 27 th ,
2015

Diagnose
Mild Head Injury +
Closed Fracture left
Neck Femur +
closed Fracture Left
ulna distal 3rd
transverse
displaced

Treatment
VS Obs + GCS
O2 + Head Up 30
IVFD NS
Antibiotic
Analgetic
H2 Blocker
Complete blood
count
Skull Xray, Thorax
xray
Head Ct scan
Co. To.
Neurosurgery :
conservative
Co. Orthopaedi:
ORIF Elective
Arthroplasty

1. Mr. Masrani/ 58 y.o /1.19.40.09/10.00

am
CC : Lump at right scrotal region
Since 3 day before admission, patient
complained about lump at his right scrotal region
that couldnt be reduced by himself and followed
by progressive pain. History of reducible lump
since 5 months ago. Lump appeared when patient
did heavy activity , and reduced when he got
rest. Nausea (+) and vomiting (+), difficult to
defecate (+), fever (-). History of lifting heavy
stuff (+). There is no complain of urinating.
Because of his complain he was brought to Ulin
hospital.

 General Status :
Alert
BP: 160/90 PR: 110x/mnt RR: 24 x/mnt T: 36.6oC
conjunctiva wasnt anemic
Local Status :
Abdominal region : flat, soft, bowel sound (+)
N,tenderness (-), muscular rigidity (-)
Right groin and scrotal region: mass 10x10x8 cm in size,
bowel sound (+), tenderness (+), hyperemic (-)
DRE : normal sphyncter tone, smooth mucosa, rectal vault
wasnt collapse, tenderness (-)
Gloves : feces (-), blood (-)

Clinical picture

Laboratory Findings
Hb : 10.4
WBC

: 13.300

Trombocyte

: 314.000

Ht : 32

AST

: 33

ALT

: 44

MCV

: 76.5

Ureum

: 49

MCH

: 24.8

Creatinin

: 0.8

Blood glucose

: 102

Sodium

: 135

Potassium

: 3.5

Chlorida

: 104

MCHC
PT

: 32.5

: 11.7

APTT : 35.3
INR : 1.03

DO (27/12/ 2015)
We found:

Working Diagnosis

HIL dextra incarcerated

Management
VS obs
IVFD RL 20 tpm
NGT& DC
Antibiotic
Analgetic
H2 blocker
Thorax Xray
Complete blood count
Co. To Digestive surgery
Herniorrhapy

2. Mr. Lamrah/ 64 y.o /1.19.40.15/12.00

am

CC : Weakness

HT :

Since 3 days prior to admission, patient

complained weakness. Patient had history of
lump in her right breast since 1 years before
admission. The lump increasingly and enlarged
and become ulcer. History of bleeding and pus (-).
History of another lump (-) . Patient had five son.
History of breast feeding (+). History of family
with breast cancer (-). History of hormonal
contraception (-). Patient had ben chemotherapy
for 8 times. History of biopsy in her lump (+). It
said
Carcinoma
ductal.
Because
of
her

Vital sign
Alert, weak
BP : 110/60 mmhg
PR : 112 x/min
RR : 28x/min
T : 36.60 C
Sat. O2: 96 %

General Status

Localis status
Ar Right breast : mass
(+) , hyperemis (+), ulcer
(+), pus (-), bleeding (-),
sized 25x20x10cm
Lymph node at axilla
billateral +/-,
supraclavicula (-),
infraclavicula (-)

Chest Xray

Laboratory Findings
Hb : 5.0
WBC : 14.900

AST

: 63

ALT

: 40

Ureum

: 78

Creatinin

: 2.6

Sodium

: 99.8

MCH : 19.7

Pottasium

: 4.8

MCHC : 30.4

Chlorida

: 73.3

PT

Blood glucose

: 146

Albumin

: 3.2

Protein

: 7.6

Trombocyte
Ht : 16.4
MCV : 65.2

: 12.1

APTT : 30.8
INR : 1.06

: 507.000

Working Diagnosis
Ca.Mammae Dx T4cN1Mx Karnofsky
score 40+ Anemia + Electrolite
imbalance

Management:
VS obs
IVFD NS 20 tpm
Antibiotic
Analgetic
H2 blocker
Thorax Xray
Complete blood count
Blood Transfusion
Co. To Oncology surgery
USG Hepar, check IHC

3.Mrs. Siti Habibah/ 59 y.o /1.19.40.13/11.30 am

CC : Pain at right hand and right hip
HT : since 4 hours before admision patient had
traffic accident when he across the road suddenly
he hit by motorcycle. History of uncosciousness
(-), bleeding from ear,nose and mouth (-). History
of nausea and vomiting (-). After the accident she
complained pain and wound at her right hand and
his right leg. Because of her complained she
brought
to Anshari Saleh hospital and then
referred to Ulin hospital for further treatment.

Primary survey :
A : Clear, no c-spine control
B : RR 20x/m, symmetrical shape and movement,
VBS equal
C : HR : 88x/m, BP: 110/70 mmHg
D : GCS 15 E4V5M6, pupil round equal 3mm, light reflex +/+, parese -/-, BH (-/-), BS
(-/-). BR (-/-), BO (-/-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 3 hours before accident
E = Environtment on the road

Head

Head
: open wound (-) haematoma (-)
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : moist mucous membrane,
Neck
: Increasion level of JVP (-)

General Status
Chest

Abdomen

Extremities

I : symmetric respiratory movement, no retraction

P : symmetric VF
P : sonor at all lung fields
A : symmetric VBS, right =left, rhonchi (-),
wheezing (-)

I : distension (-)hematoma(-)
A : normal Bowel sound
P : defence muscular (-) tenderness (-) , rebound
tenderness (-)
P : thymphani (+)

warm extremities,CRT<2 sec, edema -/-, parese -/-,

see localis status

Local status
a/r Right Antebrachii

Deformity (+), swelling (+), wound

sized 0.5x0.5 cm, based on muscle,
bleeding (+)

Tenderness (+), crepitation (-), distal

neurovascular (+). A.radialis (+),
A.Ulnaris (+)

ROM active and passive limited due

to pain

Local status
a/r Right Hip

Deformity (+), swelling (+),

shorthening(-)

Tenderness (+), crepitation (-), distal

neurovascular (+). A.tibialis post (+), A.
Dorsalis pedis (+)

ROM active and passive limited due to

pain

Clinical Picture

xray

Laboratory Findings
Hb : 10.5
WBC : 13.400
Trombocyte

: 217.000

Ht : 32.8

AST

: 28

MCV : 77.6

ALT

: 25

MCH : 24.8

Ureum

: 140

Creatinin

: 0.6

Blood glucose

: 132

MCHC : 32.0
PT

: 9.5

APTT : 21.2
INR : 0.84

Working Diagnosis
Open Fracture Right End Radius distal
+ Closed Fracture Right Neck femur

Management
VS obs
IVFD RL 20 tpm
Antibiotic
Analgetic
H2 blocker
Thorax Xray
Complete blood count
Hip xray, Antebrachii xray
Co. To Orthopaedi:
ORIF Elective and Arthroplasty
Admitted to Aster

4. Mr. M. Marzuki/ 57 y.o /1.19.40.24/11.00

pm

CC : Decrease of consciousness

HT :

Since 4 hours prior to admission, patient

got accident when he was riding a motorcycle,
He hit by another motorcycle from the back side
and his head hit the ground. Helmet (-). The
mechanism
is
unknown.
History
of
unconsciousness (+). History of vomiting (+).
History of bleeding in ear (-), nose (-), mouth (-).
Because of his complained, he brought to Banjar
baru hospital then referred to Ulin Hospital for
further treatment.

Primary survey :
A : gurgling suction OPA, without c-spine control
B : RR 24 x/m, symmetrical shape and movement,
VBS equal
C : HR : 124 x/m; TD: 150/90
D : GCS 7 E1V2M4, pupil anequal , 5 mm/3mm. light reflex +/+, parese (-/-), BH (+/-), BS (-/-) ,
BR (-/-), BO (-/-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 1 hours before accident
E = Environtment on the road

General Status

Clinical picture

Head CT-scan

Working Diagnosis
Severe Head Injury + IVH + SDH at
left temporal

Management
VS Obs + GCS
O2 + Head Up 30
IVFD NS
Antibiotic
Analgetic
H2 Blocker
Complete blood count
Skull Xray, Thorax xray
Head Ct scan
Patient discharged by request

5. Mr. Wayan Sudarte/ 36 y.o /

1.19.40.32/05.00 pm

CC : Decrease of consciousness

HT :

Since 8 hours prior to admission, patient

got accident when he was riding a motorcycle,
He crushed with another motorcycle from behind
his head hit the ground. Helmet (-). The
mechanism
is
unknown.
History
of
unconsciousness (+). History of vomiting (+).
History of bleeding in ear (-), nose (-), mouth (-).
Because of his complained, he brought to Pleihari
hospital then referred to Ulin Hospital for further
treatment.

Primary survey :
A : clear, without c-spine control
B : RR 24 x/m, symmetrical shape and movement,
VBS equal
C : HR : 88 x/m; TD: 130/90
D : GCS 10 E2V3M5, pupil equal , 3 mm/3mm. light reflex +/+, parese (-/-), BH (-/-), BS (-/-) ,
BR (-/-), BO (-/-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 3 hours before accident
E = Environtment on the road

General Status

Clinical Picture

Head CT-scan

Laboratory Findings
Hb : 15.7
WBC : 15.800
Trombocyte

: 206.000

AST

: 45

ALT

: 22

Ureum

: 36

Creatinin

: 1.0

MCH : 30.7

Blood glucose

: 128

MCHC : 34.2

Sodium

: 138

PT

Potassium

: 3.9

Chloride

: 111

Ht : 45.9
MCV : 90.1

: 10.4

APTT : 28.8
INR : 0.91

Working Diagnosis
Moderate Head Injury + contusio
cerebri at left frontal

Management
VS Obs + GCS
O2 + Head Up 30
IVFD NS
Analgetic
H2 Blocker
Complete blood count
Skull Xray, Thorax xray
Head Ct scan
Co. To. Neurosurgery
conservative

6. Mr. Kaliani/ 24 y.o /1.19.40.05/08.00

am
CC : pain and wound at left elbow, right and left
shoulder, left back, head, left hand
Since 2 days before admission patient had
attacked with sword by people. After the incident
he complained pain and wound on his left hand,
left elbow, right and left shoulder, left back, and
head. Because of it, patient brought to Rantau
hospital and had been performed primary suture
and hand xray then referred to to Ulin hospital
for further treatment.

Primary survey :
A : Clear, without c-spine control
B : RR 20x/m, symmetrical shape and movement,
VBS equal
C : HR : 72x/m; TD: 110/60
D : GCS 15 E4V5M6, pupil round equal 3mm, light reflex +/+, pharase (-/-) , BH (-/-), BS (-/-),
BR (-/-), BO (-/-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 3 hours before accident
E = Environtment

General Status

Local status
a/r Left Elbow

Deformity (+), swelling (+), wound (+)

irregular edge, sized 15x10 cm, bone
exposed, active bleeding (-)

Tenderness (+), crepitation (-), distal

neurovascular (+)

ROM active and passive limited

Clinical picture

Working Diagnosis
Traumatic amputation at Left elbow +
Multiple Vulnus scissum at right
shoulder, left shoulder, left back,
head

Management
VS Obs + GCS
O2
IVFD RL
Antibiotic
Analgetic
H2 Blocker
Complete blood count
Skull Xray, Thorax xray
Patient discharged by request

7. Mr. Muhammad Nuryasin/ 27 y.o /

1.19.40.43/11.00 pm

CC : Decrease of consciousness

HT :

Since 8 hours prior to admission, patient

got accident when he was riding a motorcycle,
He crushed with another motorcycle from the
opposite direction ,he felt and his head hit the
ground. Helmet (+). History of unconsciousness
(+). History of vomiting (+). History of bleeding in
ear (-), nose (-), mouth (-). Because of his
complained, he brought to pleihari hospital then
referred to Ulin Hospital for further treatment

Primary survey :
A : Clear, without c-spine control
B : RR 20x/m, symmetrical shape and movement,
VBS equal
C : HR : 80 x/m; TD: 120/70
D : GCS 14 E3V5M6, pupil round equal 3mm, light reflex +/+, pharase (-/-) , BH (-/-), BS (-/-),
BR (-/-), BO (-/-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 5 hours before accident
E = Environtment on the road

General Status

Clinical picture

Skull xray

Head Ct-scan

Laboratory Findings
Hb : 14.2
WBC : 14.100
Trombocyte

: 245.000

AST

: 44

ALT

: 28

Ureum

: 41

Creatinin

: 1.3

MCH : 29.7

Blood glucose

: 119

MCHC : 34.4

Sodium

: 138

PT

Potassium

: 3.9

Chloride

: 105

Ht : 41.2
MCV : 86.2

: 9.7

APTT : 26.3
INR : 0.86

Working Diagnosis

Mild Head Injury

Management
VS Obs + GCS
O2 + Head Up 30
IVFD NS
Analgetic
H2 Blocker
Complete blood count
Skull Xray, Thorax xray
Head Ct scan
Co. To. Neurosurgery:
Conservative

8. Mr. Nadjamuddin/ 66 y.o /1.19.40.36/11.30 pm

CC : Pain at his left thigh and left arm

HT :

Since 6 hours prior to admission, patient

got accident when he was riding a motorcycle,
He crushed with another motorcycle from the
opposite direction ,he felt to the left side and his
head hit the ground. Helmet (+). History of
unconsciousness (+). History of vomiting (-).
History of bleeding in ear (-), nose (-), mouth (-).
After the accident he complained pain at his left
thigh. Because of his complained, he brought to
Anshari saleh hospital then referred to Ulin
Hospital for Ct scan and further treatment

Primary survey :
A : Clear, without c-spine control
B : RR 20x/m, symmetrical shape and movement,
VBS equal
C : HR : 78 x/m; TD: 100/60
D : GCS 14 E3V5M6, pupil round equal 3mm, light reflex +/+, pharase (-/-) , BH (-/-), BS (-/-),
BR (-/-), BO (-/-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 6 hours before accident
E = Environtment on the road

Head

Head
: brill haematoma( -/+) batle sign (-)
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : moist mucous membrane,
Neck
: Increasion level of JVP (-)

General Status
Chest

Abdomen

Extremities

I : symmetric respiratory movement, no retraction

P : symmetric VF
P : sonor at all lung fields
A : symmetric VBS, right =left, rhonchi (-),
wheezing (-)

I : distension (-)
A : normal Bowel sound
P : defence muscular (-) tenderness (-) , rebound
tenderness (-)
P :Thymphani (+)

warm extremities,CRT<2 sec edema (-), parese (-),

local status

Local status
a/r Left Hip

Deformity (+), swelling (+),

shortening (-)

Tenderness (+), crepitation (-),

distal neurovascular (+)

ROM active and passive limited due

to pain

Clinical picture

Xray

Thorax xray

Head Ct scan

Laboratory Findings
Hb : 8.0
WBC : 12.900
Trombocyte

: 181.000

AST

: 125

ALT

: 122

Ureum

: 54

Creatinin

: 1.5

MCH : 28.1

Blood glucose

: 119

MCHC : 32.1

Sodium

: 138

PT

Potassium

: 3.9

Chloride

: 177

Ht : 24.9
MCV : 87.8

: 9.2

APTT : 26.8
INR : 0.82

Working Diagnosis
Mild Head Injury + Closed Fracture
left Neck Femur + closed Fracture
Left ulna distal 3rd transverse
displaced

Management
VS Obs + GCS
O2 + Head Up 30
IVFD NS
Analgetic
H2 Blocker
Complete blood count
Skull Xray, Thorax xray
Head Ct scan
Co. To. Neurosurgery:
Conservative
Co. To Orthopaedi :
ORIF Elective + Arthroplasty