Emergency Case Report

June 18th – 19th 2020

Resident On Duty
Riz Sanfebrian Adiatma

DPJP ER:
Dr. dr. Hery Poerwosusanta, Sp.B, Sp.BA, FICS
Digestive Surgery :-

Thoracic, Cardiac and Vascular Surgery :-

Plastic, Reconstruction & Esthetic Surgery :-

Urology : -

Neuro Surgery : 1 Patient

Pediatric Surgery :-

Oncology Surgery : 1 Patient

Orthopedic & Traumatology :-

Total : 2 Patients
 Patient List
No Identity Admission to ER Diagnosis Treatment

1. Ch. Febby/5yo/MR June 18th 2020 at Hydrocephalus non Treatment in ER :

1460300 10.00 am communicans e.c tumor IVFD D5 ½ NS 1300cc/24 hours
Infratentorial Inj Ranitidin 2x25mg
Inj Paracetamol 3x160mg
Inj Ondancentron 2 mg if needed

Consult Neurosurgery:
Pro Cito VP shunt
Post Op PICU
 Patient List
No Identity Admission to ER Diagnosis Treatment

2. Mrs. Rusdiana / 59 y.o/ June 18th 2020 at Ca Mammae dextra Treatment on ER

RM 1432748 10.00 PM T4bN1M1 on kemoterapi +
Effusi Pleura dextra Suspect
Malignant + Anemia + DM
type II
Karnofsky 60-70 %
• IVFD RL loading 1000cc
• Maintenance with RL 1500cc/24
hours
• Inj. Levofloxacin 1x500mg
• Inj. Omeprazol 1x40mg
• Inj. Ondancentron 4 mg
• Wound toilet with metronidazole
powder
Consul to oncologist:
• Hospitalized
• Transfusion with PRC 2 kolf/days
until HB more than 10
• Inj Leucogen 300mcg
 Ch. Febby/5yo/MR 1460300
Admitted June 18th 2020 at 10.00 am

Chief Complain : headache

History taking : she complained of headache since 1 year before admitted. Headache was felt
intermittently and progressive. Pain was throbbing and worsen when midnight. Headache is
followed by dizziness, nausea, and vomiting. Patients also often fall if walking alone without
apparent reason. She also felt his vision gradually worsen during 2 months ago. Now she can
only see flashes of light. Abdominal pain (-), chest pain (-), tightness (-), stubborn (-), travel
history out of town (-). Appetite was still good, patients during illness sleep more often than
do activities, sleep sometimes not comfort.

History of Past illness : -

History of Family Illness: Malignancy (-)
 Vital Sign
HR : 122 bpm (regular, strong)
RR : 26 bpm
Tax : 36,7 0C
GCS : E4V5M6
SpO2 : 100% without 02 Supply
Weight : 16kg
Physical Examination
• Sclera icteric (-/-), pale conjungtiva (-/-), pupil equal 4 mm|4 mm, light reflex (+|+)
Head minimal, head circumference 54 cm, venectation (+), sunset eye (+), Visus 1/∞,1/∞

• I : symetric respiratory movement, retraction (-)

Chest • P : sonor at all lung fields
• A : symmetric VBS, rhonchi (-), wheezing (-)

• I : distension (-)
• A : bowel sound (+) normal
Abdomen • P : soft, tenderness (-), defense muscular (-) tenderness (-) mass (-) ascites (-)
• P : tympani at all region

Extremities • warm extremities (+), edema (-), paresis (-), lateralization (-)
Neurological State
• GCS E4V5M6
• Pupil unequal 4 mm|4 mm, minimal light reflex
• Meningeal sign (-)
• Babinsky reflex (+)
• Lateralization (-)
Clinical Picture
 Laboratory Finding
Examination Result Normal Value
Hemoglobin 13,8 12,00-16,00 g/dl
Leukosit 3,6 4,0-10,5 ribu/ul
Eritrosit 4,98 3,90-5,50 juta/ul
Hematokrit 40 37,00-47,00 vol%
Trombosit 326 150-450 ribu/ul
RDW-CV 12,2 11,5-14,7 %
MCV 80,3 80,0-97,0 fl
MCH 27,7 27,0-32,0 pg
MCHC 34,5 32,0- 38,0 %
Neutrofil% 50,8
Limfosit% 36,5
Monosit% 8,8
Neutrofil# 1,84
Limfosit# 1,32
Monosit% 0,32
 Laboratory Finding
Examination Result Normal Value

PT 11,7 9.9 -13.5 detik

APTT 29 22.2- 37.0 detik
INR 1,09
Random Blood Glucose 115 <200.00 mg/dl
SGOT 50 5-34 u/l
SGPT 18 0-55 u/l
Ureum 13 10-50 mg/dl
Creatinin 0,47 0.6-1.2 mg/dl
Natrium 136 135-146 mmol/L
Kalium 4,2 3,4-5,4 mmol/l
Chlorida 109 95-100 mmol/l
Chest X-Ray from
Ulin Hospital
18/06/2020
Non-contrast and contrast CT Scan
24/04/2020 at Kotabaru Hospital
 Diagnosis
hydrocephalus non comunicans e.c tumor Infratentorial
Management
Treatment in ER :
• IVFD D5 ½ NS 1300cc/24 hours
• Inj Ranitidin 2x25mg Consult Neurosurgery:
• Inj Paracetamol 3x160mg • Pro Cito VP shunt
• Inj Ondancentron 2 mg if needed • Post Op PICU
 Mrs. Rusdiana / 59 y.o/ RM 1432748
Admitted at June 18th 2020 at 10.00 PM
Chief Complain : general weakness
History : Patient complained general weakness since 4 days before admitted. She felt his
body weak and loss of appetite. She also nausea and vomite, she vomite his food, blood (-).
She also complained pain at the right breast ulcer since. The pain was not accompanied by
high fever and headache.
Before that, she had lump at the right breast. Its size like a quaille egg, and became bigger
like takraw ball during 6 months (TDT 22,5 days).
She never felt shortness of breath, full in the abdomen, pain in the bone and headache. She
only had decrease of appetite and lost of weight more than 10 kg in the last 3 months.
Her first menstruation when she aged 14 years old, and her last menstruation 49 years old.
She had 3 children, and never had abortus. Lactation history (+), contraception (-) KB
History of chemoterapy : She already had chemoterapy 5 times.
Family history : (-)
Vital Sign
• BP : 110/70 mmHg
• HR : 110 bpm (regular, strong)
• RR : 20 tpm
• Tax : 36,80C
• Karnofsky Score : 60-70%
• SpO2 : 97%
• VAS : 3/10
Physical Examination
• Head : Pale conjunctiva (+|+), light reflex (+|+), Edema palpebra (-/-), sclera
icteric (-/-)
Head • Mouth : Moist mucous membrane
• Neck : enlargement of the lymph node (-)

• I : symmetrical respiratory movement, retraction (-), venectation (-), ulkus and pus
at mammae dx  see local state
Chest • P : symmetrical VF
• P : Sonor
• A : SN vesikuler, no ronchi , no wheezing

• I : distension (-), mass (-)

• A : Bowel sound (+) normal
Abdomen • P : soft, tenderness (-), liver / spleen / mass can’t be palpapted
• P : timpani at all regio

Extremities • warm, parese (-/-)

 Local Status
a/r mammae dextra:
• I : mass (+), ulcer (+), skin dimpling (-),
active bleeding (-), necrotic tissue (+), pus
(+), irregular margin, peau d orange (-)
• P : mass (+), hard consistency, pain (+),
immobile at right breast, irregular surface
(+)
a/r axilla dextra et sinistra
• I : mass (+), irregular border, ulcus (-)
• P : mass (+), conglomeration of lymph (-),
immobile
Clinical photos
orax June, 18th 2020
USG Abdomen 31 Juli 2019
PA
 Laboratory Finding 11-4-2018
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 8,6 12,00-16,00 g/dl
Leukosit 0,9 4,0-10,5 ribu/ul
Eritrosit 3,22 3,90-5,50 juta/ul
Hematokrit 24,6 37,00-47,00 vol%
Trombosit 185 150-450 ribu/ul
RDW-CV 13,7 11,5-14,7 %
MCV 76,4 80,0-97,0 fl
MCH 26,7 27,0-32,0 pg
MCHC 35 32,0- 38,0 %
Neutrofil% 19,8
Limfosit% 28,6
Monosit% 51,6
Neutrofil# 0,18
Limfosit# 0,26
Monosit# 0,47
 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
GDS 256 < 200 mg/dl
SGOT 23 0-46 U/l
SGPT 14 0-45 U/l
Ureum 20 10-50 mg/dl
Creatinin 0,63 0.6-1.2 mg/dl
Natrium 136 135-146 mmol/L
Kalium 4.5 3,4-5,4 mmol/l
Chlorida 108 95-100 mmol/l
 Working Diagnosis
Ca Mammae dextra T4bN1M1 on kemoterapi + Effusi Pleura dextra
Suspect Malignant + Anemia + DM type II

Karnofsky 60-70 %
Treatment
Treatment on ER
• IVFD RL loading 1000cc
• Maintenance with RL 1500cc/24
hours
• Inj. Levofloxacin 1x500mg
• Inj. Omeprazol 1x40mg
• Inj. Ondancentron 4 mg
• Wound toilet with metronidazole
powder
Consul to oncologist:
• Hospitalized
• Transfusion with PRC 2 kolf/days
until HB more than 10
• Inj Leucogen 300mcg