Emergency Case Report

TEMPLATE

Resident on Duty : dr. Jacky Junaedi
dr. Immanuel Hendro
Chief Co-Assistant :
Inas

Team :
Dwiputra, Annandra, Dita, Hafidz, Hidayati,
Puja

Minor Surgery :-

Digestive Surgery :1

Thorax Cardiovascular Surgery : -

Plastic Surgery :-

Urology Surgery :1

Neurosurgery :1

Pediatric Surgery :1

Oncology Surgery :-

Orthopaedy :-

Total :3

Patient List
No Identity Admission Diagnosis Treatment
to E.R.
1. Mrs. Anni April 24th Post VP Shunt a/i HC ec IVH + VS Obs
Suspek ventriculitis + IVFD NS
Danelson/ 2015 at
Hiponatremi + pressure sore OPA
19.00
67yo/1-14 - WITA
Inj Antibiotic
64-13 Inj analgesic
Rawat luka
Enteral Diet via NGT
Pro lumbal punction

Consult to
Neurosurgeon
Hiponatremia
Correction
Hospitalized

A L R CT ECG

Patient List
No Identity Admission Diagnosis Treatment
to E.R.
2. Mr. Gusti April 24th Obstructive Jaundice VS Obs
observation ec Susp CBD Cyst + IVFD Asering
Noor / 2015 at
Choleliihiasis + Moderate rehydrating
20.10
46yo/0-96 - Cholangitis + Hyponatremia Inj. Antibiotic
WITA Inj. Analgesic
79-57
Inj. H2Blocker

Complete blood
count
Thorax X ray

Consult to Digestive
surgeon:
Antibiotic
Abdominal CT SCAN
AFP & Gamma GT
Test
Rehydration and
hyponatremia
correction
Hospitalized
A L R CT ECG

Mr.R. 2015 at hyperplasia + HIL dextra Inj antibiotic 20. 3. Mahyuni April 24th Post sectio alta due Urine VS Obs retention due to Prostate IVFD RL 41yo/1-14 -86.30 WITA reponible Inj analgesic 65 Inj H2Blocker Complete blood count Consult to Urology surgeon: USG Urology PSA Consult to Digestive department Hospitalized Consult to digestive surgeon: Treat the HIL first Planing herniotomy + hernioraphy A L R CT ECG . Patient List No Identity Admission to Diagnosis Treatment E.

She later got referred to Suaka Insan hospital and underwent (EVD) surgery there. the patient consciousness level was getting better. Mrs. According to her family. before she got permanent drainage. she was unable to be awaken. she was hospitalised in ICU for 28 days.1. Anni Danelson/ 67yo/1-14 -64-13 April 24th 2015 at 19. L R CT ECG . According to her family. The examination results showed hemorrhagic stroke and intracranial hemorrhagic. Her family rushed her to Kapuas Hospital.00 WITA  Chief Complain : Decreasing level of consciousness  History : ± 36 days before admission patient experienced decreasing level of consciousness when she was sleeping. She had more responses to external stimulus and got transferred to the regular hospital wing before got dismissed by permission. Afterwards.

the patient got referred to Ulin Hospital for further treatment. The patient often got fever too. Her family rushed her to Dorrys Sylvanus Hospital and got hospitalised there for 4 days. She has began to be less responsive and eventually no more conscious. . The patient has been staying at home for 4 days. but her condition was getting worse. Due to her conditions. The patient has begun to develop open wound on her coccyges area due to prolong bedridden.

1oC A L R CT ECG .Vital Sign  BP : 140/90 mmHg  PR : 90 bpm  RR : 20 tpm  T : 37.

Rebound pain (-) Muscular Defense (-) • P : Tymphani • Warm extremities. wheezing (-/-) • I : distension (-). edema palpebra (-/-) • Mouth : Wet mucous • Neck : Lymph nodes enlargement (-/-). no retraction • P : Symmetric VF Chest • P : Sonor at all lung fields • A : symmetric VBS. • Head : normocephali General Head/Neck Status • Eyes : anemic conjunctiva. edema (-). motoric (difficult to evaluate) Extremities Sensory (difficult to evaluate) A L R CT ECG . (-/-) icteric sclera (-/-). JVP enhancement (-/-) • I : Symmetric respiratory movement. convex (+) • A : Bowel sound (+) normal Abdomen • P : Liver/spleen/kidney not palpable. rhonchi (-/-). mass not palpable Tenderness (-).

lateralization (-) A L R CT ECG . Round and symmetric pupils diameter (2mm/2mm). parese (-/-/-/-). Light reflexes (+/+).Neurological Status  GCS E2V2M3 (7).

Clinical Pictures A L R CT ECG .

Local Status A L R CT ECG .

7 % MCV 88.00 – 5.00 4.50 million/ul Hematocrit 35.0 – 38.3 11.00 Vol% Thrombocyte 581 150 – 450 Ribu/ul RDW-CV 16.0 – 97.6 4.0 Fl MCH 27.00 – 44.Laboratory Result April 24th 2015 Items Result Normal Value Unit Hemoglobine 10.0 Pg MCHC 30.18.00 g/dl Leukocyte 16.3 32.0 27.5 32.0 % A R CT ECG .5 thousand/ul Eritrocyte 4.0 – 32.3 80.0 – 10.00 .81 14.5 – 14.

0 % Lymphosite% 8.00 million/ul Gran# 14.0 Billion/ul MID# 1.1 Billion/ul A R CT ECG .50-7.0 % MID% 6.5 4. Items Result Normal Value Unit Gran% 85.00 Billion/ul Limfosit # 1.2 50.0-40.25-4.0-70.4 1.10 2.00-11.3 25.

2-37.7-1. Items Result Normal Value Unit GDS 337 <200 Mg/dL PT 11.5 g/dL Ureum 29 10-50 mg/dL Creatinin 0.4 22.9-13.4-5.97 SGOT 54 0-46 U/l SGPT 51 0-45 U/l Albumin 3.4 mg/dL Natrium 120.6 0.8 3.2 95-100 mmol/L A R CT ECG .1 135-146 mmol/L Kalium 4.5 Second APTT 25.5-5.4 mmol/L Chloride 79.1 9.0 3.0 Second INR 0.

Thorax X-Ray April 22nd 2015 at Suaka Insan Hospital A L CT ECG .

Head CT-SCAN April 24th 2015 A L R ECG .

ventriculitis + Hyponatremi A L R CT ECG .Working Diagnosis Post VP Shunt a/i HC ec IVH + S.

Management  VS Obs  IVFD NS  Inj Antibiotic  Inj analgesic  Inj H2Blocker  Enteral Diet via NGT  Complete blood count  Consult to Neurosurgeon  Pro lumbal punction  Hyponatremi Correction  Hospitalised A L R CT ECG .

2. The patient has been passing pale stool on recent days. The patient has no history of alcohol consumption. the patient went to Tanah Bumbu hospital for medical help before got referred to Ulin Hospital for further examination. Due to his complaints. Mr.10 WITA  Chief Complain : yellowish body  History : Patient has been complaining that his body turned yellowish since ± 2 weeks before admission. even though he has never experienced it before. History of DM nor HT denied. It’s getting worse with intermittent fever. L R CT ECG . His complain getting worse each day. Gusti Noor / 46yo/0-96 -79-57 April 24th 2015 at 20. The patient also has been complaining upper right quadrant abdominal pain since last 2 weeks.

8oC  SpO2: 98% A L R CT ECG .Vital Sign  BP : 100/60 mmHg  PR : 108 bpm  RR : 22 tpm  T : 36.

(-/-) icteric sclera (+/+). motoric Sensory 5 3 + + A L R CT ECG . edema palpebra (-/-) • Mouth : Wet mucous • Neck : Lymph nodes enlargement (-/-). no retraction • P : Symmetric VF Chest • P : Sonor at all lung fields • A : symmetric VBS. Rebound pain (-) Muscular Defense (-) • P : Tymphani 5 3 + + Extremities • Warm extremities. mass not palpable. JVP enhancement (-/-) • I : Symmetric respiratory movement. edema (-). Abdomen Tenderness (+) a/r right upper quadrant. • Head : normocephali General Head/Neck Status • Eyes : anemic conjunctiva. wheezing (-/-) • I : distension (-). rhonchi (-/-). convex (+) • A : Bowel sound (+) normal • P : Liver/spleen/kidney not palpable.

Rectal Touche  Anal sphincter tone (strong)  Mucous membrane sleek and smooth  Ampulla recti was not collapsed  Mass was not palpable  Tenderness (-)  BCR (+)  Faeces (+) yellow. Blood (-) .

Clinical Pictures A L R CT ECG .

convex (+) A : Bowel sound (+) normal P : Liver/spleen/kidney not palpable. Rebound pain (-) Muscular Defense (-) P : Tymphani A L R CT ECG . mass not palpable.Local Status a/r abdomen I : distension (-). Tenderness (+) a/r right upper quadrant.

7 % MCV 89.4 11.00 g/dl Leukocyte 23.5 32.0 Fl MCH 29.7 4.5 – 14.0 – 38.00 Vol% Thrombocyte 130 150 – 450 Ribu/ul RDW-CV 19.70 27.Laboratory Result April 24th 2015 Items Result Normal Value Unit Hemoglobine 13.00 – 5.0 14.0 % A R CT ECG .50 million/ul Hematocrit 38.0 – 10.00 – 44.0 – 32.37 4.00 .5 thousand/ul Eritrocyte 4.18.0 – 97.0 Pg MCHC 33.4 80.8 32.

00 million/ul Gran# 19.0 % Lymphosite% 7.9 = non reactive A R CT ECG .4 4.00 Billion/ul Limfosit # 1.0 % MID% 11.0 Billion/ul MID# 2.25-4.00-11.5 50.0-70.7 1.30 2. Items Result Normal Value Unit Gran% 81.1 25.7 Billion/ul HBs Ag (Cobas) Negative < 0.50-7.0-40.

5-5.0 6.4 mg/dL Natrium 121.00-0.16 0.7 135-146 mmol/L Kalium 1.4 mmol/L Chloride 76.40 Mg/dL Bilirubin Total 23.52 0.2-0. Items Result Normal Value Unit GDS 90 <200 Mg/dL Bilirubin Direct 13.2-8.9 0.64 0.4 3.0 mg/dL Albumin 2.7-1.2-1.4-5.5 g/dL Ureum 197 10-50 mg/dL Creatinin 1.8 3.6 95-100 mmol/L A R CT ECG .6 Mg/dL SGOT 100 0-46 U/l SGPT 57 0-45 U/l Protein total 6.2 Mg/dL Bilirubin Indirect 9.

Thorax X-Ray April 22th 2015 at Tanah bumbu Hospital A L CT ECG .

USG April 22nd 2015 at Tanah Bumbu Hospital A L R ECG .

Working Diagnosis  Obstructive Jaundice observation ec Susp CBD Cyst + Choleliihiasis + Moderate Cholangitis + Hyponatremia A L R CT ECG .

Management  VS Obs  IVFD Asering rehydrating  Inj. H2Blocker  Complete blood count  Thorax X ray  Consult to Digestive surgeon:  Antibiotic  Abdominal CT SCAN  AFP & Gamma GT Test  Rehydration and hyponatremia correction  Hospitalized A L R CT ECG . Antibiotic  Inj. Analgesic  Inj.

He also have to push to put it out. no history of abdominal distention. The patient often awoken at night to urinate. There no history of bloody stool. The patient got referred shortly afterwards. They were planned to put permanent cable to him. The patient has history of unsatisfying miction since a year ago. but according to his family and the nurses. the patient was unable to urinate at all.3. 1 day before admission. the surgery was unsuccessful due to adhesion. Mahyuni 41yo/1-14 -86-65 April 24th 2015 at 20. Patient has history lump on right groin for last 5 years. He got catheter installment at Buntok Hospital before got referred to Ulin Hospital. L R CT ECG . The lump came out when the patient stand and release if patient lay down.30 WITA  Chief Complain : Post Operation  History : ± 1x24 hours before admission. Mr. there no history of nausea and vomitus. the patient was underwent surgery due to his prostate enlargement which caused him unable to miction. It was frequent and usually painful.

7oC A L R CT ECG .Vital Sign  BP : 120/80 mmHg  PR : 90 bpm  RR : 20 tpm  T : 36.

convex (+) • A : Bowel sound (+) normal Abdomen • P : Liver/spleen/kidney not palpable. edema (-). Rebound pain (-) Muscular Defense (-) • P : Tymphani 5 5 + + Extremities • Warm extremities. wheezing (-/-) • I : distension (-). • Head : normocephali General Head/Neck Status • Eyes : anemic conjunctiva. edema palpebra (-/-) • Mouth : Wet mucous • Neck : Lymph nodes enlargement (-/-). motoric Sensory 5 5 + + A L R CT ECG . mass not palpable Tenderness (-). JVP enhancement (-/-) • I : Symmetric respiratory movement. rhonchi (-/-). (-/-) icteric sclera (-/-). no retraction • P : Symmetric VF Chest • P : Sonor at all lung fields • A : symmetric VBS.

operation scar (-/-) • Pal : mass was not palpable. hematoma (-/-).CVA • Ins : bruise (-/-). folley catheter (+) • Penis : edema (-) hematom (-) • Skrotum : edema (-) hematom (-) post surgical scars(-) . lump (-) Drainage (+) 50cc blood • Pal : vesica urinaria impalpable. tenderness (-/-) • Per : CVA (-/-) Flank Area • Insp: mass (-/-). edema (-). hematoma (-/-) • Pal : Mass was not palpable. hematoma (-). tenderness (-/-) Suprapabic • Ins : bruise (-). mass impalpable tenderness (-) Genitalia • OUE : bloody discharge (-).

Rectal Touche  Anal sphincter tone (strong)  Mucous membrane sleek and smooth  Ampulla recti was not collapsed  Mass was not palpable  Tenderness (-)  BCR (+) Gloves  Faeces (+) yellow. Blood (-) .

Clinical Pictures A L R CT ECG .

Local Status A L R CT ECG .

4 80.0 Pg MCHC 32.18.9 27.2 4.00 million/ul Hematocrit 41.0 – 97.0 % A R CT ECG .44 14.0 Fl MCH 29.0 – 38.00 .5 11.7 % MCV 92.50 – 6.0 – 32.4 32.48 4.3 32.00 Vol% Thrombocyte 385 150 – 450 Ribu/ul RDW-CV 12.0 – 10.00 – 44.Laboratory Result April 24th 2015 Items Result Normal Value Unit Hemoglobine 13.00 g/dl Leukocyte 12.5 thousand/ul Eritrocyte 4.5 – 14.

Items Result Normal Value Unit Gran% 80.0 Billion/ul MID# 0.0-40.25-4.1 4.8 1.6 Billion/ul A R CT ECG .6 25.00 million/ul Gran# 9.50-7.0-70.8 2.00-11.0 % Lymphosite% 14.00 Billion/ul Limfosit # 1.0 % MID% 5.3 50.

95 SGOT 47 0-46 U/l SGPT 47 0-45 U/l Ureum 54 10-50 mg/dL Creatinin 1.4 mmol/L Chloride 99.2-37. Items Result Normal Value Unit GDS 159 <200 Mg/dL PT 10.4-5.8 95-100 mmol/L A R CT ECG .2 0.5 Second APTT 24.4 mg/dL Natrium 134.1 3.0 Second INR 0.7-1.9-13.7 22.8 9.9 135-146 mmol/L Kalium 4.

Thorax X-Ray April 24th 2015 A L CT ECG .

BNO X-Ray April 23rd 2015 at Buntok Hospital Impression: Suspect Uretrhrolithiasis DD Prostate calcification A L CT ECG .

Working Diagnosis  Post sectio alta due Urine retention due to Prostate hyperplasia + HIL dextra reponible A L R CT ECG .

Management  VS Obs  IVFD RL  Inj antibiotic  Inj analgesic  Inj H2Blocker  Complete blood count  Consult to Urology surgeon:  USG Urology  PSA  Consult to Digestive department  Hospitalized  Consult to digestive surgeon:  Treat the HIL first  Planing herniotomy + hernioraphy A L R CT ECG .