Doctors on duty:

On Site Consultant :

Irfansyah, MD, SpB

Members : Endang Syuhada

Mutiara Ayu Putri Anjela Pratiwi
Shintya Lestari
Siti Haryati
Syalfa Luthfira Nugroho
Wulan Mulyani
Yeyen Satriyani
Trauma patients : patients
Non trauma patients : patients
Total patients : patients
 TRAUMA CASES
• Paidi / ♂ / 53 y.o
Dx: Abcess cruris
 NON TRAUMA CASES
• Sriyatin
Dx: Cholelitiasis
• Joni Aryo Raharjo/ ♂ / 60 y.o
Dx: Post Ileustomi
Suprapti / Female / 42 y.o
Dx: Susp. Appendicitis Chronic
• Adam Amrullah / ♂ / 19 y.o
Dx: Mass Intra Abdominal
• M. Farid Hisam / ♂ / 53 y.o
Dx: colic abdomen ec susp ca colon
• Beryl raizel khanri / ♂ / 13 y.o
Dx: snake bite
• Afriyana /female / 59 y.o
Dx: Gangren pedis sinistra digiti 345
• Suprapti / female / 42 y.o
Dx : app chronic
 TRAUMA CASES
• Paidi / ♂ / 53 y.o
Admitted on Wednesday, September 15th 2021 at 15.20

Pain of injury in the right leg

e.c crushed by rock 1 month ago
At first the leg swell, pinkness, and there is pus in the wound
Past medical history DM (-), hypertension (-), gastritis (+)

VITAL SIGN
Sense : CM
BP : 114/71 mmHg
HR : 70 x/m
RR : 20 x/m
T : 36,7ºC
SpO2 : 97%
PHYSICAL EXAMINATION

On the crus region

I : wound in the right crus region ±10 cm, eritema
(+), edema (+), pus (+)
P : Tenderness (+)
LABORATORY FINDINGS
Leukosit : 8,77 103/µl (5 – 10 103/µl)
Glucosa : 82 mg/dl

DIAGNOSIS
Abcess Cruris

THERAPY
- IVFD RL 20 tpm
- Ketorolac 2x1
- Handling wound
- Planning Debridement at September 16th, 2021

Patient was treated in the ward

• Paidi / ♂ / 53 y.o
Follow up on Thursday, September 16th 2021 at 05.30

Pain (+), Fever (+)

VITAL SIGN
Sense : CM
BP : 110/63 mmHg
HR : 89 x/m
RR : 20 x/m
T : 38,9ºC
SpO2 : 99%
PHYSICAL EXAMINATION

On the crus region

I : wound in the right crus region ±10 cm, eritema
(+), edema (+), pus (+)
P : Tenderness (+)
 NON TRAUMA CASES
• Sriyatin/Female/ 36 years old
Admitted on Sunday, September 12th 2021 at 19.00 pm

ANAMNESIS
Pain (-), Vomit (-), Flatus (+), defecate (+), in the stoma
Past medical (-), The patient said upper right abdominal pain since 2 years ago, The patient has
had treatment, the complaints improve after taking the medicine and the pain returns after the
medicine is finished

VITAL SIGN
Sense : CM
BP : 121/79 mmHg
HR : 65 x/m
RR : 20 x/m
T : 36,5ºC
• PHYSICAL EXAMINATION

On the abdominal region

I : Flat. Distension (-)
P : Bowel sounds (+) normal
P : Right hypochondrium (+) tenderness,
mass/tumor (-)
A : Tympany (+)
 LABORATORY FINDINGS
Hb: 13.2 gr/dl (14 – 18 g/dl)
Ht : 39.9 vol% (41 – 54 vol%)

DIAGNOSIS
Cholelitiasis

THERAPY
Planning Laparotomy at September 13th, 2021

Patient was treated in the ward

 NON TRAUMA CASES
• Joni Aryo Raharjo/ ♂ / 60 y.o
Admitted on Monday, September 13th 2021 at 15.16

Pain (-). Vomit (-). Flatus (+), defecate (+) in the stoma
Past medical history peritonitis ec ileum perforation and colostomy surgery 8
months ago.

VITAL SIGN
Sense : CM
BP : 113/73 mmHg
HR : 83 x/m
RR : 20 x/m
T : 36,5ºC
SpO2 : 95%
PHYSICAL EXAMINATION

On the abdominal region

I : stoma in the right iliaca region and post-op
wounds in the suprapubic region
P : Tenderness (-)
P : Tympani
A : Bowel sound (+)
 LABORATORY FINDINGS
Hb : 11,7 gr/dl (14 – 18 g/dl)
Ht : 37,6 vol% (40 – 48 vol%)

DIAGNOSIS
Post Ileustomi

THERAPY
- Anastomosis ileum at September 15th, 2021

Patient was treated in the ward

 NON TRAUMA CASES
• Suprapti / Female / 42 y.o
Admitted on Thursday, September 16th 2021 at 03.

Pain of lower right stomach ±1 month ago, the pain is getting worse since 1 week
ago, pain is also felt in the upper abdomen, nausea (-), vomit (-), fever (-),
anorexia (-), flatus (+), defecate (+)
Past medical history DM (-), hypertension (-)

VITAL SIGN
Sense : CM
BP : 152/91 mmHg
HR : 106 x/m
RR : 20 x/m
T : 36,5ºC
SpO2 : 99%
PHYSICAL EXAMINATION

On the abdominal region

I : Scar (-)
P : Tenderness in Mc’Burney (+), Rebound
Tenderness (+), Rovsign’s sign (+), Psoas sign (+)
P : Tympani
A : Bowel sound (+)
LABORATORY FINDINGS
Leukosit : 22,69 103/µl (5 – 10 103/µl)
Neutrofil : 90,8 mg/dl (50-70 mg/dl)

DIAGNOSIS
Susp. Appendicitis Chronic

THERAPY
- IVFD RL 20 tpm
- Ceftriaxone
- Planning Laparotomy at September 16th, 2021

Patient was treated in the ward

 NON TRAUMA CASES
• Adam Amrullah / ♂ / 19 y.o
Admitted on Wednesday, September 15th 2021 at 18.30

Pain of left abdomen ± 1 week ago

Nausea (+), vomit (+), Flatus (+), Defecate (+)
Past medical history DM (-), hypertension (-)

VITAL SIGN
Sense : CM
BP : 114/71 mmHg
HR : 70 x/m
RR : 20 x/m
T : 36,7ºC
SpO2 : 97%
PHYSICAL EXAMINATION

On the abdominal region

I : Distensi (+), Scar (-)
P : Tenderness (-), Mass (+)
P : Dim (+)
A : Bowel Sound (+)
LABORATORY FINDINGS
Leukosit : 13.93103/µl (5 – 10 103/µl)

DIAGNOSIS
Mass Intra Abdominal

THERAPY
- IVFD RL 20 tpm
- Ceftriaxone
- Planning Laparotomy at September 16th, 2021

Patient was treated in the ward

• PONINTEN / Female / 51 y.o
follow up on Tuesday, September 14th 2021 at 05.30

Pain on post op laparotomi (+). Nausea (+). Vomit (+). Flatus (+),
defecate (+) in the drain on abdomen
Past medical history Ca Colon Descendant and history of and
laparotomy and colostomy

VITAL SIGN
Sense : CM
BP: 107/73 mmHg
HR : 107 x/m
RR : 20 x/m
T : 37,1ºC
SpO2 : 99%
GDS : 221
PHYSICAL EXAMINATION

On the abdominal region

I : stoma in the left .......... region and post-op
wounds in the epigastrium until suprapubic region
P : Tenderness (+)
P : Tympani
A : Bowel sound (+)
• Katiyo / Male / 56 y.o
follow up on Tuesday, September 14th 2021 at 05.30

Pain on post op appendectomy (+). Nausea (-). Vomit (-). Flatus

(+), defecate (-)
Past medical history Appendicitis Chronic and history of
appendectomy

VITAL SIGN
Sense : CM
BP: 137/75 mmHg
HR : 52 x/m
RR : 20 x/m
T : 37,1ºC
SpO2 : 96%
PHYSICAL EXAMINATION

On the abdominal region

I : post-op wounds in the right iliaca region
P : Tenderness (+)
P : Tympani
A : Bowel sound (+)
• Sriyatin / female / 36 y.o
follow up on Tuesday, September 14th 2021 at 05.30

Pain on post op laparascopy (+). Nausea (+). Vomit (+). Flatus (+), defecate
(-)
Past medical history cholelithiasis and history of laparascopy

VITAL SIGN
Sense : CM
BP: 121/79 mmHg
HR : 99 x/m
RR : 20 x/m
T : 36,5ºC
SpO2 : 98%
PHYSICAL EXAMINATION

On the abdominal region

I : post-op wounds in the right hypochondriac,
epigastric, right lumbar region
P : Tenderness (+)
P : Tympani
A : Bowel sound (+)
• Sriyatin / female / 36 y.o
follow up on Thursday, September 16th 2021 at 05.30

Pain on post op laparascopy (+). Nausea (-). Vomit (-).

Flatus (+), defecate (+)
Past medical history cholelithiasis and history of laparascopy

VITAL SIGN
Sense : CM
BP: 106/77 mmHg
HR : 90 x/m
RR : 20 x/m
T : 35,8ºC
SpO2 : 95%
PHYSICAL EXAMINATION

On the abdominal region

I : post-op wounds in the right hypochondriac,
epigastric, right lumbar region
P : Tenderness (+)
P : Tympani
A : Bowel sound (+)
 NON TRAUMA CASES

• M Farid Hisam/ ♂ / 53 y.o

Admitted on thrusday, September 16th 2021 at 12.42

right side abdominal pain, limp since 2 days,

flatus(-), poop 2 days ago

VITAL SIGN
Sense : CM
BP: 121/99 mmHg
HR : 105 x/m
RR : 21 x/m
T : 36,7ºC
PHYSICAL EXAMINATION

On the abdominal region

I : Flat, Hematom (+)
P : Tenderness in right side of abdomen (+)
P : Faint
A : Increased Bowel Sounds (+)
LABORATORY FINDINGS
Leukosit : 30,12 103/µl (5 – 10 103/µl)
GDS : 148,0 mg/dl (< 140 mg/dl)
Ureum : 75,8 mg/dl (19-44 mg/dl)
PH : 7,57 (7,35-7,45)
Natrium : 124,04 mmol/L ( 135-145)

DIAGNOSIS
Colic abdomen ec susp ca colon

THERAPY
- IVFD RL 20 tpm
- Ranitidin 2x1
- Ketorolac 1 ampule
- Ngt alir
- Ceftriaxon 2x1
- Planning ct scan

Patient was treated in the ward

 NON TRAUMA CASES
• Beryl Raizel Khanri/ ♂ / 13 y.o
Admitted on thrusday, September 16th 2021 at 19.51

was bitten by a snake after caming home from the

mosque after being bitten the patient said it was sore
and painful in the right leg

VITAL SIGN
Sense : CM
BP: 106/64 mmHg
HR : 77 x/m
RR : 20 x/m
T : 36,2ºC
PHYSICAL EXAMINATION

On the abdominal region

I : Abdominal wall at chest level
P : Tenderness (-), liver and spleen not palpable
P : Tympani
A : Bowel sounds (+) normal
DIAGNOSIS
Snake bite

THERAPY
- IVFD RL 2 vial sabu + nacl 500cc

Patient was treated in the ward

 NON TRAUMA CASES

• Afriyana/ Female / 59 y.o

Admitted on thrusday, September 16th 2021 at 15.20

wound on left leg since 1 week not healing,DM (+)

VITAL SIGN
Sense : CM
BP: 140/100 mmHg
HR : 130 x/m
RR : 20 x/m
T : 36,2ºC
PHYSICAL EXAMINATION

On the abdominal region

I : Abdominal wall at chest level
P : Tenderness (-), liver and spleen not palpable
P : Tympani
A : Bowel sounds (+) normal
LABORATORY FINDINGS
Hemoglobin : 11,5 g/dl (12 – 16 g/dl)
Hematokrit : 33,4 % ( 37-48)
Trombosit : 472 103/µl (150-450)
Mpv : 10,60 Fl (7,3-9)
GDS : 358,0 mg/dl (< 140 mg/dl)

DIAGNOSIS
Gangren pedis sinistra digiti 345

THERAPY
- IVFD RL 20 tpm
- Monitor TTV
- Persiapan OP amputasi digiti

Patient was treated in the ward

 NON TRAUMA CASES
• Suprapti/ female/ y.o
Admitted on thrusday, September 16th 2021 at

VITAL SIGN
Sense : CM
BP: 140/80 mmHg
HR : 95 x/m
RR : 20 x/m
T : 36,9ºC
PHYSICAL EXAMINATION

On the abdominal region

I : Abdominal wall at chest level
P : Tenderness lower left quadrant (+)
LABORATORY FINDINGS
Lekosit : 22,69 103/µl (5– 10 g/dl)
MCV : 92,1 Fl (80-92)
Netrofil Segmen : 90.8% (50-70)
GDS : 149,0 mg/dl (< 140 mg/dl)
Limfosit : 5,2% (20-40)

DIAGNOSIS
Susp App acute

THERAPY
- IVFD RL 20 tpm
- Monitor TTV
- Persiapan OP appendiktomi

Patient was treated in the ward