Emergency Report

September 2nd 3th 2016

Resident on duty:
dr. Shanti Fernandez
Coass on duty :
Barra, Aldish, Dewi, Irfan,
Christi

General Surgery

Digestive Surgery

Thorax Cardiovascular Surgery :

Plastic Surgery

Urology Surgery

Neuro Surgery

Pediatric Surgery

Total

:
:

2
:

Oncology Surgery
Orthopaedy

Patient List
No

Identity

1.

Mr. Abdul
Azis/ 64
y.o

Admission
to ER
September
2nd 2016

Diagnose
Difuse Peritonitis e.c susp.
Perforation hollow viscus +
Hipovolemik syok no respon +
AKI

Treatment

VS Obs
O2
Head up 30 deg
IVFD NS
Antibiotic
H2 blocker
Complete blood
count
X-Ray
CT - Scan
NGT - Urine
Catheter
Co.to Digestive
surgery KIE
Patient discharge
by request

Patient List
No
2.

Identity
Mrs.
Rasinah/
46 y.o

Admission
to ER
September
2nd 2016

Diagnose
Moderate Head Injury + SDH
at Right Frontotemporal (16cc)
+ ICH at Left parietal (6cc) +
edem cerebri + Midline shift to
the left 2 mm

Treatment

VS Obs
VS GCS
O2 3lpm
Head up 30 deg
IVFD NS
Antibiotic
Analgetic
H2 blocker
Manitol
Complete blood
count
X-Ray
CT Scan
DC
Co.to Neuro
surgery
Pro Cito Craniotomi
evacuation
Post Op ICU

Patient List
No
3.

Identity

Admission
to ER

Mrs.
September
Faridah/ 48 2nd 2016
y.o

Diagnose
Mild Head Injury + fr.
Maxilozygomaticus + Rima
orbita

Treatment

IVFD NS
Antibiotic
Analgetic
H2 blocker
O2 2 lpm
Complete blood
count
Head CT Scan
Co.to Neuro
surgery
Conservative
Co. to Plastic
Surgery
Hospitalized

Patient List
No

Identity

Admission
to ER

4.

Mr Pandi /
55 y.o

September
2nd 2016

Diagnose
Abdominal pain e.c
susp.peritonitis e.c perforasi
appedicytis dd abdominal TB
+ Right Contracted kidney/
nephritis chronis et chronic
cystitis

Treatment

IVFD RL
Antibiotic
Analgetic
H2 blocker
Complete blood
count
Co. to Digetive
Surgery

Patient List
No
5.

Identity

Admission
to ER

Mr Farhan / September
60 y.o
2nd 2016

Diagnose
SOL Supratetorial

Treatment

IVFD NS
Kortikosteroid
Antibiotic
Analgetic
H2 blocker
Complete blood
count
Co. to Neuro
Surgery
Patient discharge
by request

1. Tn.Abdul Azis/ 64 y.o

Chief Complain :
Decrease of conciousness
Current History :
Since 15 minutes before admission, patient got
decrease of conciousness while he brought to Ulin
hospital. He got pain at his abdomen since a day
ago. He has hospitalized for a day at RS Datu
Sanggul Rantau. Before he got pain, he
complained about defecate 5 times, and last
defecation was a day ago. Nausea (+), vomiting
3 times (+), fever (+) since one day ago . Then he
brought to Ulin General Hospital for further
treatment.

Vital sign

BP: immeasurable
Hr: 83 tpm
RR: 28 tpm
T 36 0C

Phisic
Diagnostic

Head
:simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)

Chest

I : Symmetric respiratory movement, no retraction

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

Abdomen

I : distension (+) flat.

A : Bowel sound (-)
P : defance muscular (+) at whole abdomen,
P : Hyperthympani (+)

Head

General Status

Extremities

cold extremities, edema (-), parese (-)

Clinical picture
DRE : normal sphyncter tone,
smooth mucosa, mass (-),
rectal vault wasnt collapse,
tenderness (-)
Gloves : feces (+), blood (-),
secret (+)

Laboratory
Examination

Result

Normal value

hemoglobin

16.0

11.00-16.00

g/dl

Leucosit

7.9

4.0-10.5

Thousand /ul

eritrosit

5.41

4.50-6.00

milion /ul

hematocrit

44.6

42.00-52.00

Vol%

trombocit

171

150-450

Thousand /ul

Random Blood
Glucose

88

<200

Mg/dL

SGOT

105

0-46

U/I

SGPT

89

0-45

U/I

Urea

147

10-50

Mg/dL

Creatinine

3.5

0.7-1.4

Mg/dL

HBs Ag Ultra

Negative

X ray

Working Diagnosis
Difuse Peritonitis e.c susp.
Perforation hollow viscus +
Hipovolemik syok no respon +
AKI

MANAGEMENT
VS Obs
O2
Head up 30 deg
IVFD NS
Antibiotic
H2 blocker
Complete blood count
X-Ray
CT - Scan
NGT - Urine Catheter
Co to Digestive Surgery KIE
Patient Discharge by request

2. Mrs. Rasinah/ 46 y.o

Chief Complain :
Decrease of conciousness
Current History :
Since 30 minutes before admission, patient got
accident. He was a ride on a motorcycle with her
husband. helmet (+), and hit another motorcylce
from side back direction. The mechanism of
trauma, patient was fall down at ground. history
of unconsciousness (-) history of vomiting (+) at 3
times, history of bleeding from ear nose and
mouth (-/+/-). After the accident, Patient refered
to Bhayangkara hospital and patient brought to
Ulin for further treatment

Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP : 140/90 HR : 86x/m;
D : PCS 14 E3V5M6, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(-/-) BR (+)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal 2 hours before accident
E = Environment on the street

Secondary
survey Head
Head

:simetric, normocephal, brill haematom (-) batle

sign (-) , BO(-/-) BR(+), V.laceratum a.r Temporoparietal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)

General Status

Chest

I : Symmetric respiratory movement, no retraction

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

Abdomen

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

A : Bowel sound normal
P : defence muscular (-) tenderness (-) mass (-)
P : Tymphani (+)

Extremities

warm extremities, edema (-), parese (-)

Clinical picture

Laboratory
Examination

Result

Normal value

hemoglobin

12,4

11.00-16.00

g/dl

Leucosit

15,1

4.0-10.5

Thousand /ul

eritrosit

4.20

4.50-6.00

milion /ul

hematocrit

37,8

42.00-52.00

Vol%

trombocit

348

150-450

Thousand /ul

Random Blood
Glucose

128

<200

Mg/dL

SGOT

52

0-46

U/I

SGPT

49

0-45

U/I

Urea

33

10-50

Mg/dL

Creatinine

0,9

0.7-1.4

Mg/dL

Ct Scan

Working Diagnosis
Moderate Head Injury + SDH at
Right Frontotemporal (16cc) +
ICH at Left parietal (6cc) + edem
cerebri + Midline shift to the left
2 mm

MANAGEMENT
VS Obs
VS GCS
O2 3lpm
Head up 30 deg
IVFD NS
Antibiotic
Analgetic
H2 blocker
Manitol
Complete blood count
X-Ray
CT Scan
DC

Co to Neuro Surgery Pro Cito Craniotomi evacuation , post op ICU

3. Mrs. Faridah/ 48 y.o

Chief Complain :
Headache
Current History :
Since 30 minutes before admission, patient got
accident at pramuka street. He was a ride on a
motorcycle. helmet (+), and suddenly fall down
and her head hitted by ground. The mechanism of
trauma, patient was fall down at ground. history
of unconsciousness (+) at 15 minutes. history of
vomiting (+) at 1 times, history of bleeding from
ear nose and mouth (+/-/-). After the accident,
Patient brought to Ulin for further treatment

Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP : 110/80 HR : 92x/m;
D : PCS 15 E4V5M6, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(+/+) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal 2 hours before accident
E = Environment on the street

Secondary
survey Head
Head

:simetric, normocephal, brill haematom (-) batle

sign (-) , BO(+) BR(-) excoriated wound (+)
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)

General Status

Chest

I : Symmetric respiratory movement, no retraction

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

Abdomen

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

A : Bowel sound normal
P : defence muscular (-) tenderness (-) mass (-)
P : Tymphani (+)

Extremities

warm extremities, edema (-), parese (-)

Maxilofacial status
At rima orbita : deformity (-), swelling
(-), bone discontinuity (-), diplopia (-)
At zygoma: deformity (-), swelling (-),
step off defect (-), crepitation (-)
At maxilla (S) : deformity (-), open
wound (-), swelling (+), floating (+),
tenderness (+), crepitation (-), bone
discontinuity (-), step off defect (-),
floating maxilla (-)
At mandibula: deformity (-), open wound
(-), swelling (-)

Clinical picture

CT Scan

Skull AP

Laboratory
Examination

Result

Normal value

hemoglobin

12,3

11.00-16.00

g/dl

Leucosit

17,3

4.0-10.5

Thousand /ul

eritrosit

3,64

4.50-6.00

milion /ul

hematocrit

37

42.00-52.00

Vol%

trombocit

229

150-450

Thousand /ul

Random Blood
Glucose

184

<200

Mg/dL

SGOT

37

0-46

U/I

SGPT

29

0-45

U/I

Urea

31

10-50

Mg/dL

Creatinine

0,7

0.7-1.4

Mg/dL

Working Diagnosis
Mild Head Injury + fr.
Maxilozygomaticus + fr. Rima
orbita

IVFD NS
Antibiotic
Analgetic
H2 blocker
O2 2 lpm
Complete blood count
Head CT Scan
Co.to Neuro surgery
Conservative
Co. to Plastic Surgery
Hospitalized

4. Mr. Pandi/ 55 y.o

Chief Complain :
Pain at right lower abdomen
Current History :
Since 2 day ago before admission, she felt pain at
his lower right abdomen. The pain was initially
felt at epigastric region, and then moved and
remained at right lower abdominal region. The
pain not accompanied of History Nausea (-),
vomiting (-), fever (-), History of jaundice (-).
There were no complaint in defecating. History of
use analgetik drugs (-). He was brought to
Amuntai Hospital, and he was hospitalized for 2
day and then He refered to ulin general hospital

Vital sign

BP: 130/90 mmHg

Hr: 86 tpm
RR: 20 tpm
T 36,5 0C

Phisic
Diagnostic
Head

Head
:simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi (+/-), no wheezing (-/-)

General Status

Chest

Abdomen

Extremities

I : distension (-) flat.

A : Bowel sound (+)
P : defance muscular (+) at Mc Burney Sign, Psoas sign
(+), Obturator sign (+)
P : Thympani (+)

Warm extremities, edema (-), parese (-)

Clinical picture
Local Status :
- Abdominal region :
distension (-) flat, Bowel
sound (+)
defance muscular (+) at Mc
Burney Sign, Psoas sign (+),
Obturator sign (+),
Thympani (+)

DRE : normal sphyncter

tone, smooth mucosa,
rectal vault wasnt
collapse, tenderness (-)
, Gloves : feces (+),
blood (-), secret (-)

Laboratory RSU Pambalah Batung

31-8-2016

Examination

Result

Normal value

Hemoglobin

13,9

11.00-16.00

g/dl

Leucosit

9,0

4.0-10.5

Thousand /ul

eritrosit

4.94

4.50-6.00

milion /ul

hematocrit

30,1

42.00-52.00

Vol%

trombocit

299

150-450

Thousand /ul

Random Blood
Glucose

74

<200

Mg/dL

SGOT

26

0-46

U/I

SGPT

30

0-45

U/I

Urea

30,6

10-50

Mg/dL

Creatinine

1,0

0.7-1.4

Mg/dL

Laboratory RSU Pambalah Batung

2-9-2016

Examination

Result

Normal value

Hemoglobin

12,0

11.00-16.00

g/dl

Leucosit

7,5

4.0-10.5

Thousand /ul

eritrosit

4.29

4.50-6.00

milion /ul

hematocrit

30,9

42.00-52.00

Vol%

trombocit

196

150-450

Thousand /ul

Random Blood
Glucose

113

<200

Mg/dL

SGOT

15

0-46

U/I

SGPT

13

0-45

U/I

Urea

24

10-50

Mg/dL

Creatinine

1,13

0.7-1.4

Mg/dL

X-Ray

Usg Abdomen

Working Diagnosis
Abdominal pain e.c
susp.peritonitis e.c perforasi
appedicytis dd abdominal TB +
Right Contracted kidney/ nephritis
chronis et chronic cystitis

MANAGEMENT
IVFD RL
Antibiotic
Analgetic
H2 blocker
Complete blood
count
Co. to Digetive
Surgery

5. Mr. Farhan/ 56 y.o

Chief Complain :
Decrease of conciousness
Current History :
Since 1 day ago before admission, suddenly
patient got a decrease of conciousness, before
that, patient got vomiting 2 times with
continously of headache and not cured with
medicineThe pain felt since 1 year ago. Short of
breathness (-), Parase (-), convulsi (-), fever (-).
There were no complaint in defecating. History of
HT (-), History of DM (-), history of trauma
accident (-) He was brought to neurologist and
patient brought to Banjarbaru Hospital, and then

Vital sign

BP : 140/90
Hr: 88 tpm
RR: 24 tpm
T 36 0C

Phisic
Diagnostic

Head
:simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)

Chest

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-/-), no wheezing (-/-)

Abdomen

I : distension (-) flat.

A : Bowel sound (+)
P : defance muscular (-)
P : Thympani (+)

Head

General Status

Extremities

Warm extremities, edema (-), parese (-)

Clinical picture

Laboratory
Examination

Result

Normal value

hemoglobin

18,1

11.00-16.00

g/dl

Leucosit

10,2

4.0-10.5

Thousand /ul

eritrosit

5,65

4.50-6.00

milion /ul

hematocrit

55,9

42.00-52.00

Vol%

trombocit

338

150-450

Thousand /ul

SGOT

30

0-46

U/I

SGPT

30

0-45

U/I

Urea

75

10-50

Mg/dL

Creatinine

1,0

0.7-1.4

Mg/dL

X-Ray

CT Scan

Kesimpulan :
Oligodendroglioma

Working Diagnosis
SOL Supratetorial

MANAGEMENT
IVFD NS
Kortikosteroid
Antibiotic
Analgetic
H2 blocker
Complete blood count
Co. to Neuro Surgery
Patient discharge by request