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EMERGENCY

REPORT
MAY 15TH
16TH 2017

Chief on Duty :
Julia

Coass on Duty:
Rizal Anshari, Eka, Ayu, Baihaki, Faisal, Ida, Syifa
General Surgery :
4
Digestive Surgery : 1
Thorax Cardiovascular Surgery : 0
Plastic Surgery : 0
Urology Surgery : 1
Neuro Surgery : 2
Pediatric Surgery : 0
Oncology Surgery :
1
Orthopaedy Surgery : 0
Total : 9 patients
Admission to
No Identity Diagnosis Treatment
ER
1 Ch. May 15th 2017 SHI GCS 8 + C Spine control
Rusdianor/15 14.30 wita Diffuse brain Insert OPA
y.o injury Suction
O2 nasal canul
Marshalls class
IVFD NS 18 dpm
IV + depressed Analgetic
fracture of the Antibiotic
frontospenoidal H2 Blocker
dextra Tetanus prophylaxis
communitive Complete blood count
displaced+ Xray Trauma Series
closed fracture CT Scan trauma
Consult to Neuro surgery:
of the right
Informed family about bad
maxilla prognosis
incomplete+ Hopitallized to ICU
Multiple VL and Nimodipine 4x2 tab/ngt if
VE a/r frontalis. theres no resistence.
Manitol 6x100 cc with minimal
BP 110/60.
Consult to plastic sugery:
Hospitallized.
Admission to
No Identity Diagnosis Treatment
ER
2 Ny. Yuliani/40 May 15th 2017 Recurrent O2 Nasal canul
yo 15.00 wita carcinoma IVFD RL 20 dpm
mammae CBC
sinistra post
Consult to Oncology surgery:
MRM on oral Hospitallized
chemotherapy Analgetic
+ Pleural Antibiotic
effusion susp Corcicosteroid
lung
metastases

Karnofsky score
40-50
Admission to
No Identity Diagnosis Treatment
ER
3 Ch. Nazwa May 15th 2017 MHI GCS 15 + Wound toilet
Ramadhan / 16.00 wita Vulnus Wound haecting
10 y.o laceratum ar Skull AP/Lat
frontalis Observation for 6 hours
sinistra
Admission to
No Identity Diagnosis Treatment
ER
4 Mr. Ujang/ 61 May 15th 2017 MHI GCS 14 + IVFD NS 20 dpm
y.o 17.00 wita susp basilar Antibiotic
fracture+ Analgesic
persistent H2 Blocker
cephalgia CT Scan

Consult to Neuro Surgery:


Hospitalized
Admission to
No Identity Diagnosis Treatment
ER
5 Mr. Dendy/ 24 May 15th 2017 Wound Wound toilet
y.o 19.30 wita dehiscence et Wound haecting
causa trauma Tetanus prophylaxis
+ susp elbow (refused)
dislocation Xray Left elbow (refused)

Discharged by request
Admission to
No Identity Diagnosis Treatment
ER
6 Ms. Febriyani May 15th 2017 Right temporo- Analgetic
L/ 25 y.o 21.30 wita mandubular
joint pain Discharged by permissions
Refer to polyclinic
Admission to
No Identity Diagnosis Treatment
ER
7 Mr. Saili/ 67 May 15th 2017 Working Insert DC
y.o 20.00 wita diagnosis: Discharged by permission
Retentio urine Refer to polyclinic
Etiological
diagnosis: BPH
Complication
diagnosis: -
Additional
diagnosis: -

IPSS 24
Admission to
No Identity Diagnosis Treatment
ER
8 Mrs. Norlian/ May 16th 2017 Chronic IVFD RL 20 dpm
67 y.o 01.30 wita diarrhea + Analgetics
Intrabdominal H2 blocker
mass susp ca CBC
colon
Consult to digestive
surgery:
Hospitallized
Hypochalemia correction
Albumin transfusion
Planned for Colon in loop
Admission to
No Identity Diagnosis Treatment
ER
9 Ms. Rabiatul May 16th 2017 Abdominal pain IVFD RL 20 dpm
Jannah/ 17 y.o 22.30 wita ec susp Analgetics
abdominal CBC (Refused)
msucle strain. Observation for 6 hours.

Discharged by permission
Ch. Rusdianor/15 y.o
Chief Complain:
Decreases of consciousness
History of Current Disease:
Patient became unconsciouss after he had a single
traffic accident using motorcycle. A wittness said he
was riding a motorcyce in a high speed, he was
suddenly unstable, hit a tree, and fell hard to his
right. He didnt used a helmet. There was bleeding
from his right ear and nose. No history of vomitus
and seizure after the trauma. This patient was first
brought to the RS Anshari saleh, they sutured the
PRIMARY SURVEY
A: Gurgling with c spine control
B: RR: 30 tpm, regular, rh(-/-) wh(-/-), SpO2 99% with O2 3 lpm
C: N: 89 bpm, strong, regular, BP: 130/80 mmhg
D: GCS E1V2M5 BH (+/-) BO(+/-) BR (+/-) non active BS (-/-),
pupil anisokhor 4mm/1mm, pupil reflex (+/+) slow responses
to the light.

Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Present illness (-)
L = Last meal 4 hours before accident
E = Environment on the street.
Physical
Examination
Neurology Status
Local status
a/r Frontalis
dextra
L: swelling (+),
hiperemis (+) , multiple
VE, VL 1x2 cm subcutis
based, VL 1x1 cm
subcutis based, VL at
supercilia dextra 8x1
cm sutured.
F: warm (+) crepitation
(-) CRT < 2dtk.
Clinical
picture
Post haecting
Local status
a/r Maxillaris
D
L: swelling (+),
hiperemis (+),
Deformity (-)
F: warm (+) crepitation
(-) CRT < 2dtk.
Local status a/r
Frontosphenoid
dextra

L: swelling (+),
hiperemis (+) , multiple
VE, deformity (-).
F: warm (+) crepitation
(-) CRT < 2dtk.
CXR
Cervical X
Ray
Ap/Lat
CT SCAN
Skull 3D
CT SCAN
Bone window
CT SCAN
Brain window
CT
SCA
N
Brain
window
Complete
blood count
Diagnosis

SHI GCS 8 + Diffuse brain injury


Marshalls class IV + depressed
fracture of the frontospenoidal dextra
communitive displaced+ closed
fracture of the right maxilla
incomplete+ Multiple VL and VE a/r
frontalis.
Management
C Spine control
Insert OPA
Consult to Neuro surgery
Suction Informed family about bad
O2 nasal canul prognosis
IVFD NS 18 dpm Hopitallized to ICU
Analgetic Nimodipine 4x2 tab/ngt if
Antibiotic
theres no resistence.
Manitol 6x100 cc with minimal
H2 Blocker
BP 110/60.
Tetanus prophylaxis
Complete blood count Consult to plastic sugery:
Xray Trauma Series Hospitallized.
CT Scan trauma
Mrs. Yuliani/ 40 y.o
Chief Complain:
Shortness of breath
History of Current Disease:
Patient compained about shortness of breath that appears
intermitently since 2 days before admissions, espescially when she
eats, drinks, and lay on her back, so she preferred to lay on her
right side. She also compained about disturbing pain on her left
neck, she felt like theres someone throbbing her neck, this pain
made her unable to slept. She had consume many analgetics to
relieves the pain, but it persist. Her doctor diagnosed left
malignant tumor on her left breast 2 years before admission, she
was underdone pre operation chemotherapy 4 times, then
undergone MRM, then goes for another chemo. After chemo, Her
Vital Sign:
BP: 120/70
P: 98 bpm
RR: 32 tpm
Temp: 36.9C
Physical Examination
Local status at
mammae sinistra

L: Operation scar +/- 6 cm,


crusta (+)
F : Tenderness (-)
Local status at
colli sinistra
L : mass (+) swelling (-)
F: multiple mass (+) around 2x3
cm, solid and hard consistency,
immobile, tenderness (+)
M: No limitation
CXR
Complete blood
counts
Diagnosis

Recidif carcinoma mammae


sinistra post MRM on oral
chemotherapy + Pleural effusion
susp lung metastases

Karnofsky 40-50
Management
O2 Nasal canul
IVFD RL 20 dpm
CBC

Consult to Oncology surgery:


Hospitallized
Analgetic
Antibiotic
Corcicosteroid
Ch. Nazwa Ramadhan /10 y.o
Chief Complain:
Lacerated wound on right forehead
History of Current Disease:
Her mother brought this patient to the ER because
a lacerated wound on her right forehead that
appears after a decorated fence fell on her head 30
minutes before admission. She was unconscious for
5 minutes, no history of vomitus, seizure, bleeding
from nose, ears, and mouth after the trauma. She
had a complete tetanus immunization status.
PRIMARY SURVEY
A: Clear without c spine control
B: RR: 28 tpm, regular, rh(-/-) wh(-/-), SpO2 99% without O2
C: N: 90 bpm, strong, regular, BP: 96/60 mmhg
D: GCS E4V5M6 BH (-/-) BO(-/-) BR (-/-) BS (-/-), pupil isokhor
4mm/4 mm, pupil reflex (+/+) rapid responses to the light.

Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Present illness (-)
L = Last meal 2 hours before accident
E = Environment by an unstable decorated fence.
Physical
Examination
Neurology Status
Local status
a/r Frontalis
sinistra

L: swelling (+),
hiperemis (+), VL 3x1
cm fascia based.
F: warm (+)
tenderness (+)
crepitation (-) CRT <
2dtk.
CLINICAL
PICTURE
POST HAECTING
SKULL
AP/LAT
Diagnosis

MHI GCS 15 + Vulnus


laceratum ar frontalis
sinistra
Managemen
t
Wound toilet
Wound haecting
Skull AP/Lat
Observation for 6 hours
Mr. Ujang/ 60 y.o
Chief Complain:
Decreases of consciousness
History of Current Disease:
This patient was a referral from Idaman Hospital with diagnosis
MHI GCS 14 and persistent cephalgia, they managed this patient
for 4 days.
This patient always looks drowsy after he had traffic accident 4
days before admissions to Ulin Hospital, he tends to close his
eyes and opened it when someone called him. The mechanism of
injury: he was working on the side of the road, and suddenly a
motorcycle hit him from the right side. He was unconscious for 5-
10 minutes, there was vomitus after the trauma, 1 times. No
seizure, bleeding from nose, ears, and mouth.
Physical
Examination
Vital Sign:
BP: 140/90
P: 82 bpm
RR: 18 tpm
Temp: 36.5C
VAS: 3
Neurology Status
Local status
a/r Frontalis
sinistra

L: swelling (-),
hiperemis (-), VL 1x1
cm sutured.
F: warm (-) tenderness
(+) crepitation (-) CRT <
2dtk.
CT
SCAN
Bone
window
CT
SCAN
Brain
window
CT
SCAN
SKULL 3D
Diagnosis

MHI GCS 15 + Susp basilar


fracture + Cephalgia
persistent+ Vulnus
laceratum ar frontalis
sinistra
Managemen
t
IVFD NS 20 dpm
Antibiotic
Analgesic
H2 Blocker
CT Scan

Consult to Neuro Surgery:


Hospitalized
Mr. Dendy/ 24 y.o
Chief Complain:
Pain on the left elbow
History of Current Disease:
This patient came to the ER complained about pain
on his left elbow, it appears after he had traffic
accident. His motorcycle slip, and he fell to his left
with his left hand first. He was using helmet, Head
impaction was denied, no history of loss of
consciousness, naussea, vomitus, seizure, bleeding
from ears, nose, and mouth.
PRIMARY SURVEY
A: Clear without c spine control
B: RR: 22 tpm, regular, rh(-/-) wh(-/-), SpO2 99% without O2
C: N: 72 bpm, strong, regular, BP: 120/80 mmhg
D: GCS E4V5M6 BH (-/-) BO(-/-) BR (-/-) BS (-/-), pupil isokhor
4mm/4 mm, pupil reflex (+/+) rapid responses to the light.

Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Present illness (-)
L = Last meal 2 hours before accident
E = Environment On the street.
Physical
Examination
Local status
a/r olecranon
sinistra
L: swelling (+)
hiperemis (+) deformity
(+) wound dehiscence
4x2 cm muscle based.
F: tenderness (+)
crepitation (-) CRT <
2dtk.
M: Limited active and
passive ROM
CLINICAL PICTURE
POST HAECTING
Diagnosis

Wound dehiscence et
causa trauma + susp
elbow dislocation
Managemen
t
Wound toilet
Wound haecting
Tetanus prophylaxis
(refused)
Xray Left elbow
(refused)

Discharged by request
Ms. Febriyani/ 25 y.o
Chief Complain:
Pain when open the mouth
History of Current Disease:
Patient compained about disturbing pain when she open her
mouth, it appears 2 day before the admission, she wasnt sure
about the cause, she just know the pain started after she wakes
up in the morning, so she assumes that it happens when she
sleeps. The pain worsen when she eats or drinks. She also had
history of finger stiff and pain about 2 month before admission,
but it only intermittent. No history of arthritis on her family.
Vital Sign:
BP: 120/70
P: 78 bpm
RR: 18 tpm
Temp: 36.4C
Physical Examination
Local status at
TMJ sinistra

L: maloclusion (-) deformity (-)


swelling (-) hiperemis (-)
F : tenderness (+) crepitation (-)
warm (+)
M: limited due to pain.
CLINICAL PICTURE
Working Diagnosis

Right
temporomandibular joint
pain
Management
Analgetics

Discharged by permissions
Refer to polyclinic
Mr. Saili/ 67 y.o
Chief Complain:
Cant urinate
History of Current Disease:
Patient cant urinate since 18 hours before admission, before cant urinate,
he compained difficult to urinate since 2 weeks before admission, the
urine were just dropping. He also had to strain to urinate, when the urine
out, stream looks weak. Patient also felt he had to urinate again not long
(about 1-2 hours) after the previous one, espescially at night, it became
more often. He never seen blood on his urine, but cloudy in 1-2 times.
Fever was denied. Patient already diagnosed has BPH since 5 years before
admission, he had the same compain. He routinely using katheter, but he
put off the catheter when he travel to Banjarmasin. The doctor suggest an
operation, but he postponed due to economic reasons.
Vital Sign:
BP: 140/100
P: 80 bpm
RR: 20 tpm
Temp: 36.5C
Physical Examination
Perineum
Ins: Fissura (-) fistula (-) hyperemia (-)
RT:
TSA strong, regular mucosa, palpable mass (-)
Prostate : non palpable upper pole, sulcus medianus
non palpable, enlarged prostate (+) diameter 4 cm
with estimated volume 64 cm3, normal consistency,
smooth surface, tenderness (+) at 12 oclock.
Feses (+) blood (-)
CLINICAL
PICTURE
CLINICAL
PICTURE
Diagnosis

Working diagnosis: Retentio urine


Etiological diagnosis: BPH
Complication diagnosis: -
Additional diagnosis: -
Management
Insert DC
Discharged by permission
Refer to polyclinic
Mrs. Norlian/ 47 y.o
Chief Complain:
Diarrhea
History of Current Disease:
Patient had diarrhea since 6 month before admission, it occurs
persistently, about 15-20 times per day. The stools contain water,
mucous, and sometimes fresh blood. She also complain intermittent
abdominal pain, espescially at the center and lower left region, about 3-4
times a day. Theres also naussea and vomitus 2-3 times a day, food
contains, blood (-). Fever (+) intermitently without any spesific patterns.
She was also cannot urinate since 3 month before admission, but this
problem already solved by insertion of the urine catheter. Theres
significant loss of appetite and weight since 6 month. History of having
round and small feses are denied. Theres no shortness breath adn
headache. Shes a referal from Kotabaru hospital, and often came their
Vital Sign:
BP: 140/70
P: 78 bpm
RR: 18 tpm
Temp: 36.4C
Physical Examination
Head : simetric, normocephal, mass (-).
Eye : Anaemic conj. (+/+), icteric sclera (-/-), edema palpebral
Head (+/+)
Mouth : Moist mucous membrane, Pale Lips Mucous (+)
Neck: Elevated JVP(-), lympadenopathy (-)

I : symmetric respiratory movement, retraction (-), bruise (-)


P : symmetric VF
Chest P : Sonor at all lung fields
A : symmetric VBS, no rhonchi, no wheezing
I : slightly covex (+)
A : Bowel sound increse. No metallic sounds
P : Palpable massa at suprapubic- ingunal sinistra 8x6 cm,
Abdomen mobile, solid, normal consistency, smooth surface, tenderness
(+), Organ Enlargment(-)
P : dull at suprapubic and ingunal sinistra.

Extremities Warm ekstremities (+) Parese (-) edema grade II (+/+) pitting.
Perineum
Ins: Fissura (-) fistula (-) hyperemia (+)
RT:
TSA less strong , regular mucosa, palpable mass (-),
pain at the 12-14 oclock(+)
Feses (+) blood (-)
CLINICAL PICTURE
USG

Tampak masa heterogen, irregular,


batas tak tegas diameter 7x6x10 pada
abdomen bawah. Tampak cairan bebas
intraperitoneal minimal.
CBC
CBC
Working Diagnosis

Chronic diarrea +
hipoalbuminemia +
hipokalemia +
intraabdominal mass susp ca
colon
Management
IVFD RL 20 dpm
Analgetics
H2 blocker
CBC

Consult to digestive surgery:


Hospitallized
Hypochalemia correction
Albumin transfusion
Planned for Colon in loop
Ms. Rabiatul Jannah/ 18 y.o
Chief Complain:
Abdominal cramps
History of Current Disease:
Patient complained about abdominal cramps that she experiences
4 hours before admission, she describe the pain as cramps and
felt like his abdominal muscle being pulled, flatus (+) defecate (+)
2 hours before admission, no naussea, vomitus, and fever. beside
abdomen, she also felt muscle cramps all over her extremities.
The pain started when she nearly finished the selection for
became a police. The selection consists of series type of physical
excercises, like running, push up, sits up, and swimming for 10
hours straight. Her friends were also experiencing the same thing,
but her parents worries and brought her to the ER.
Vital Sign:
BP: 120/80
P: 80 bpm
RR: 18 tpm
Temp: 36.5C
Physical Examination
Head : simetric, normocephal, mass (-).
Eye : Anaemic conj. (-/-), icteric sclera (-/-)
Head Mouth : Moist mucous membrane, Pale Lips Mucous (-)
Neck: Elevated JVP(-), lympadenopathy (-)

I : symmetric respiratory movement, retraction (-), bruise (-)


P : symmetric VF
Chest P : Sonor at all lung fields
A : symmetric VBS, no rhonchi, no wheezing

I : Distension (-)
A : Bowel sound normal
Abdomen P : tenderness (+) at all region, muscle defans (-), organ
enlargment(-), sign of peritoneal irritability (-)
P : Timpani at all region

Extremities Warm ekstremities (+) Parese (-) swellinga (-)


Perineum
Ins: Fissura (-) fistula (-) hyperemia (-)
RT:
TSA strong, regular mucosa, palpable mass (-),
tenderness (-)
Feses (+) blood (-)
Clinical picture
Working Diagnosis

Abdominal pain e.c


muscle strain
Management
Analgetics
CBC (Refused)
Observation for 6 hours.

Discharged by permission.