Admission to

No Identity Diagnosis Treatment

ER Patient List
1. Mis Rusmini October 27 th • Cholelithiasis IVFD RL 20 dpm
2017 Inj. Ketorolac 3x30mg
Inj. Tramadol 2x100mg
20.00 Routin Blood test

Co Digestif (20.30)
Observation in ER
No respon with analgesic, patient
admite to ward and schudeling for
elective surgery.
 1. Ms Rusmini/ 43 yo
Chief Complain:
Abdominal pain
History taking:
Pasient presented to ER with intermitten severe abdominal pain since 1 day ago. Followed
by yellowish skin and eyes, malaise, headache with No diarrhea, no nausia and vomite.
Same complain also complained two mont ago, patien had medical examonation and had
been schuled for elective surgery 30/10/2017.
 Primary survey

A: clear, with no c spine control

B: RR: 22 x/mnt, reguler, rh(+/+) wh(-/-), SpO2 98%
nasal canul O2
C: N: 82 x/mnt, strong pulse, TD 110/70 mmhg
D: GCS 15 E4V5M6, BH (-/-) BS(-/-) BO (-|-) BR (-/-)
Physical
Examination• Head
(+)
: Pale conjunctiva (-/-) Sclerea Icteric (+/+) Edema palpebra (-/-), battle sign
Head • Mouth : Moist mucous membrane
• Neck : Increased level of JVP (-), laceration (-), enlargement of lymph node (-)

• I : symmetrical respiratory movement, retraction (-), bruise(-)

• P : Symmetrical VF
Chest • P : Sonor at all lung fields
• A : symmetrical VS, no ronchi, no wheezing,
• I : distension (minimal) wound (-) hematoma(-) lacerated (-)
• A : Bowel sound (+) normal
Abdomen • P : defence muscular (-) tenderness (in epigastrium and Upper Right Quadrant),
murphy sign (+) mass (-),
• P : timpani

Extremities • warm extremities

HB : 11.7
Normal Lung and
cardio
USG Abdomen
• Dilate of hepatal billiaris
duct and ekstrahepatal susps
with common stone bile duct
• Cholecystitis
• No abnormalities on
pancreas, line, both ren,
vesica urinary or uterus
Working Diagnosis

Cholelithiasis with common bile duct stone

pro Cholesistectomy
Management
IVFD RL 20 dpm
Inj. Ketorolac 3x30mg
Inj. Tramadol 2x100mg

Co Digestif (20.30)
Observation in ER
“No respon with analgesic, patient admite to
ward and schudeling for elective surgery.”
 Admission to
No Identity Diagnosis Treatment
1. Mis Rusmini
ER
October 27th
Patient List
SOL supratentorial dd IVFD RL 20 dpm
astrocytoma Ivfd NS 20 tpm
2017 Inj ketorolac 3x30 mg
Inj Ranitidin 2x50 mg
20.30
Routin blood test
Chest X ray

Co Neurosurgery (21. 30)

admitted to Hospital (ward)
Scheduling for elective surgery
 1. Mr Suib/ 30 yo
Chief Complain:
Abdominal pain
History taking:
• Patient presented to ER with chronich headace since 1 year ago, Headache appears slowly
and berable 2 months ago, while come to ER with no nausea and vomite, the patient has
been treated in ratu zalecha Hospital and did MRI, after that patient reffered to Ulin
Hospital.
 Primary survey

A: clear, with no c spine control

B: RR: 22 x/mnt, reguler, rh(+/+) wh(-/-), SpO2 98%
nasal canul O2
C: N: 82 x/mnt, strong pulse, TD 120/70 mmhg
D: GCS 15 E4V5M6, BH (-/-) BS(-/-) BO (-|-) BR (-/-)
Physical
Examination• Head
(+)
: Pale conjunctiva (-/-) sclerea icteric (-/-) Edema palpebra (-/-), battle sign
Head • Mouth : Moist mucous membrane
• Neck : Increased level of JVP (-), laceration (-), enlargement of lymph node (-)

• I : symmetrical respiratory movement, retraction (-), bruise(-)

• P : Symmetrical VF
Chest • P : Sonor at all lung fields
• A : symmetrical VS, no ronchi, no wheezing,

• I : distension (-) wound (-) hematoma(-) lacerated (-)

• A : Bowel sound (+) normal
Abdomen • P : defence muscular (-) tenderness (-) mass (-),
• P : timpani
Motorik :
superior : 1/4 BPR: +3/+2
• warm extremities Inferior: 1/4
Extremities TPR: +3/+2
• Hemiparase dextra Sensorik : + APR:+3/+2
Tonus : eutoni KPR :+3/+2
Atrofi: (-)
Blood test
Normal Lung and
cardio
Head CT-C Scan
Head CT-C Scan

Space occupying
lesion with
Hydrocephallus and
cerebral edema
(herniasi falcial)
Dd/ strocytoma
Working Diagnosis

• SOL supratentorial dd/ strocytoma

Management
• Ivfd NS 20 tpm
• Inj ketorolac 3x30 mg
• Inj Ranitidin 2x50 mg
• Complete blood test

• Consult to neurosurgery :
admitted to Hospital (ward)
Scheduling for elective surgery