No Name, Age Working Diagnosis Triage Disposition

1 Mrs. Sumarmi, 69 Urosepsis P1 Internal

yo Hiperglicemia State Medicine

2 Mrs. Dwi, 60 yo General Weakness post GEA P2 Internal

Hypertension Stage II Medicine

3 Mr. Gandamana, AMS dt Respiratory Failure type 1 P1 Internal

65 yo Metabolic Encephalopathy Medicine
Septic Condition
CKD St V
4 Mrs. Mintarsih, 70 Tension type headache dt P2 Neurology
Hypertensive Urgency dt TIA
Moderate dehydration dt nausea
vomiting
5 Mr. Misman, 50 yo SOB dt ADHF P1 Cardiology
No Name, Age Working Diagnosis Triage Disposition

6 Mr. Abdullah, 53 yo SOB dt ADHF P1 Cardiology

7 Mr. Alfan, 33 yo AMS dt Hepatic Encephalopathy P1 Internal

Medicine
8 Mr. Herlambang, Abdominal Pain dt Susp Ileus P2 Internal
30 yo Paralitic Medicine
Moderate Dehydraton
9 Mrs. Tri, 63 yo Dizziness dt BPPV P2 Morning Shift
10 Mr. Ashari, 61 yo AMS dt Septic Pneumonia P1 Morning Shift
4
• A : Patent • P1
• B : Rapid and shallow • Support Oxygen BVM 15
• C : Cold and dry acral, Lpm
Bounding pulse, rapid, • Planning Intubation
regularly regular, BP: • IVFD NS 0.9 Loading
180/103 mmHg 500cc evaluate
• D : GCS E3V1M4, Temp:
36.6‘C, RBS: 163 mg/dL

5
Patient came to ER RSSA with AMS since 6
hours before admision. Patient start
agitation. Fever 1 week, cough (+), Sputum
Hard to cough. SOB 6 hours before
admission, worsning while patient got
nebulation.

History of past illness:

DM (+) uncontrolled

6
General Severely ill, GCS 315
appearance

Hand Cold and Dry acral, thready pulse, cyanotic(-), pale (-) , clubbing finger(-),
icteric (-), Oedem (-/-)

Head Pupil isokor, ф 3 mm/3 mm, LR -/-, anemic conjuntiva (-/-) , cyanotic
(-) ,Icteric (-/-)
Neck JV distended (+)

Chest S1 S2 Single, m-, g-, rub -

Cardiac
Lungs Thracea Deviation (S), asymmetrical movement
VBS ↓ + Rales - - Wheezing - +
↓ + - - - +
↓ + - - - +

Abdomen Distend (-), BS (-), shifting dullness (-), mass (-)

Legs pretibial oedem (-/-)

8
 23.00 23.30 01.00
Patient’s condition Patient’s condition Patient’s condition
GCS :314 GCS : 1x1 GCS : 4x4
BP : 180/103 mmHg BP : 160/80 BP : 90/62
HR : 114x/min HR : 98x/min HR : 94x/min
RR : Gasping RR : 12x via BVM RR : 12x via BVM
SpO2: 100% (BVM) SpO2: 100% SpO2: 100%
RBS: 196 mg/dl

P1 Intervention: Intervention:
Support Oxygen Via BVM Chest X ray Sounding Thoracic
15 LPM Needle Decompresion Surgery
IVFD NS 0.9 Loading Planning WSD WSD
500cc Evaluate Sounding Pulmonology Dispose (Thoracic
Planning Intubation Surgery)

Fentanyl 100mcg IV
Atracurium 25 mg IV
Intubation ETT 7.0 depth
21cm
NGT & FC insert
 Lab Result
Date 13/10/17 07:21:23
CBC : HB/RBC/ WBC/HCT/ PLT 11.80/4.23/7.99/32.70/167
Diff Count : Eo/Bas/Neu/Limf/mon 0.1/0.1/79.4/16.4/4.0
Ur / Cr 72.40/3.84
Na/K/Cl 124/3.54/96
SGOT/SGPT 22/18
Albumin 3.26
RBS 294
PPT 13.20/10.5/1.27
APTT 41.10/25.5
 Lab 13/10/17
06:37
PH 7,02

pCO2 56,3
PO2 171.3
HCO3 14.6
BE -16.5
Sat O2 98.5%
Hb 11.7
Temp 37’C
Na 124
K 3.54
Cl 96
• AMS dt Respiratory Failure type II
• Tension Pneumothorax D