Jaga 28 April 2014

Emergency ReportApril 27th-28th, 2014

Chief on duty:Syella

Resident on duty:Dr. Andika

Team:Ramza, Fairuz, Dayah, Fajar, Harry, Tari, Adit

Minor surgery : 1

Oncology surgery :

Digestive surgery :

Thorax cardiovascular surgery :

Plastic surgery :

Urology surgery :

Neurosurgery : 1

Pediatric surgery : 1

Orthopedic : 1

Total :

PATIENT LIST

Patients ListNo Identity Admission to

E.R.Diagnosis Management

1. Child Yasmin/ 7.5 months yo

April 27th, 2014 at 10.45

Total Ileus obstruction e.c Susp.invagination

BNO 3 positionUSG abdominalLaboratory Check and urinalize

IV LineAntibioticAnalgesicH2 blockerFasting NGT

No Identity Admission to E.R.

Diagnosis Management

2. Mr. Maspuad/ 54yo

April 27rd 2014 at 20.00

Corpus alienum at left thumb

Extraction corpus alienumHectingAnalgeticAntibioticH2 BlockerDischarge with permission

No Identity Admission to E.R.

Diagnosis Management

3 Mr. Ardiansyah/55 yo

April 27th 2014 at 21.45

Mild head injury + multiple vulnus laceratum

Hospitalize Thorax x-ray, head ct-scan, bone serialLaboratorium checkIv lineCatheterization (Fluid balance)HectingDressingAnalgesic H2 blocker

No Identity Admission to E.R.

Diagnosis Management

7 M. Sarto Sadi/50 yo

April 28th 2014 at 03.15

Open fracture os femur sinistra + susp. Fracture basis cranii

HospitalizeLaboratorium checkCt scancatheterization

1. Child Yasmin/ 7.5 months/ April 27th 2014 at 12.45

Chief complain: History :

±4 days before admission, patient was found often vomitting, vomit was green colored and accompanied by swollen stomach and red colored mucous like faeces. 5 days before admission, patient was having a fever, and taken by parent to a massager, the next day, vomitting started accompanied by unable to defecating. Until now, patient was consuming breast-milk and eat promina, pasien is first child in family and she was born in hospital through cessarian operation.

General StatusAwareness: alertGCS15 : E4V5M6 Vital sign• HR : 120 t/m• RR : 30 t/m• T : 37, oC• BB : 7 kg

Physical Examination• Eyes : No anemic conjunctivae, icteric sclerae (-), • Nose : No epistaxis• Mouth : wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck

• I : symmetric respiratory movement,• P : symmetric VF (+/+)• P : sonor at all lung• A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)

Chest

• I : flat, distention (+), sausage shape(-), darn contour (-), dam stiffung(-)• A : Bowel sound (-), metallic sound (-) • P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,

rebound tenderness (-)• P : Hipertympani

Abdomen

• Warm, no parese, no edemExtremities

DRE

Look

• Mass (-)• Abration (-)• Hemoroid

(-)• Oedem (-)• Eritema (-)

Feel

• Normal anal sphincter tone

• Smooth mucosa

Handschoon

• Feces (-)• Mucus (-)• Blood (-)

Laboratory Findings

• Hb : 11.0• WBC : 7.0• RBC : 4.37• Hematocrite : 33.1• Plt : 356• PT/APTT : 8.4/30.2• Na/K/Cl : 124.4/3.8/87.8

BNO abdominal, April 25th 2014 BNO abdominal, April 26th 2014

BNO Abdomen, April 27th 2014

Working Diagnosis

• Total Ileus Obstruction e.c susp invaginasi

ManagementBNO 3 posisi Laboratory Check

Consult Pediatric Surgery• Hospitalization • IV Line• Antibiotic• Analgesic• H2 blocker• Fasting • NGT• Catheterization• Fluid Balance

2. Mr. Maspuad/54 yo/ April 27th 2014 at 20.00

Chief complain: left thumb was punctured by a fishhook.History : ± 1 days before admission, patient got accident while

fishing.

Primary Survey

• Clear (+), snoring (-), gurgling(-), c-spine control (-)A• Clear, RR : 18/mt, simmetry respiratory movement, VBS

simmetryB• Pulse 98/mt,reguler, lift strong, the extremities warm• BP: 110/70 mmHg C• GCS E4V5M6, round and simmetric pupils , diameter (3mm/3mm),

light reflexes (+/+), no paralysisD

• -A• -M• -P• 6 hours before admissionL• On the riverE

Secondary Survey • Eye : anemic (-/-), icteric (-/-), palpebrae hematom (-/-)• Nose : epistaksis (-), rhinorhea (-)• Mouth : the mucosa of the lips moist• Neck : Lesion (-), hematom (-)

Head - Neck

• I: Simmetry respiratory movement• Pal: simmetry vokal fremity• Per: sonor/sonor• Aus: VBS simemetry, Rh -/-, Wh -/-

Thorax

• I: flat, lesion (-)• Aus: bowel sound (+) N• Pal: tenderness (-)• Per: timpany

Abdomen

• warm peripherals, no edema , no paralysis, other see local statusExtremities

Local Status

X- Ray

Working diagnosis

Corpus allienum at left thumb

Management

• Extraction corpus alienum• Hecting • Antibiotic • Analgetic• H2 blocker• Discharge by permission

3. Mr. Ardiansyah/55 yo/ April 27th 2014 at 21.45

Chief complain: headacheHistory : ± 6 hours before admission patient got crash accident,

while riding a motorcycle he got crash by a motorcycle. He then taken to Banjarbaru General Hospital by Police officer, noone knew how the accident happen. vomit (+), bledding at ear/nose/mouth (-/-/-).

Primary Survey

• Clear (+), snoring (-), gurgling(-), c-spine control (-)A• Clear, RR : 24/mt, simmetry respiratory movement, VBS

simmetryB• Pulse 72/mt,reguler, lift strong, the extremities warm• BP: 130/70 mmHg C• GCS E3V5M6, round and simmetric pupils , diameter (3mm/3mm),

light reflexes (+/+), no paralysisD

• -A• -M• -P• 8 hours before admissionL• On the roadE

Secondary Survey • Eye : anemic (-/-), icteric (-/-), palpebrae hematom (-/-)• Nose : epistaksis (-), rhinorhea (-)• Mouth : the mucosa of the lips moist• Neck : Lesion (-), hematom (-)• There is a vulnus laceratum in left parietal which already

sutured. And in right frontal 3x1cm with base of wound is subcutis

Head - Neck

• I: Simmetry respiratory movement• Pal: simmetry vokal fremity• Per: sonor/sonor• Aus: VBS simemetry, Rh -/-, Wh -/-

Thorax

• I: flat, lesion (-)• Aus: bowel sound (+) N• Pal: tenderness (+)• Per: timpany

Abdomen

• warm peripherals, no edema , no paralysis (motorik 5/5)• There is vulnus laceratum 2x2cm in right elbow joint Extremities

Clinical Picture

Local Status

X-ray

Head CT scan

Laboratory findings

• Hb : 12.1• WBC: 12.6• RBC: 3.79• Ht: 36.5• PLT: 223

• BSR: 161• SGOT/SGPT: 67/37• Ur/Cr: 24/1.0• Na/K/Cl: 139.9/4.4/104.7

Working diagnosis

Mild head injury GCS 14 E3M6V5Multiple vulnus laceration

Management

• Hospitalize • Thorax x-ray, antebrachial x-ray ap/lat• head CT-scan• Laboratory Check• IV line• Catheterization (fluid balance)• Hecting• Dressing

4. Mr. Sarto Sadi/50 yo/ April 28th 2014 at 03.10

Chief complain: decreased of consciousnessHistory : 12 hours before admission patient got crash accident

and he got crash by a 6 wheeled truck. and he fell down to the road. Helmet (-). After the accident patient is unconscious for 15 minutes, vomit (+), bledding at ear/nose/mouth (-/+/+)

Primary Survey

• Clear (+), snoring (-), gurgling(-), c-spine control (-)A• Clear, RR : 24/mt, simmetry respiratory movement, VBS

simmetryB• Pulse 92/mt,reguler, lift strong, the extremities warm• BP: 80/60 mmHg C• GCS E1V2M4, round and simmetric pupils , diameter (3mm/3mm),

light reflexes (+/+), no paralysisD

• -A• -M• -P• 1 days before admissionL• On the roadE

Secondary Survey • Eye : anemic (-/-), icteric (-/-), palpebrae hematom (-/-)• Nose : epistaksis (-), rhinorhea (-)• Mouth : the mucosa of the lips moist• Neck : Lesion (-), hematom (-)

Head - Neck

• I: Simmetry respiratory movement• Pal: simmetry vokal fremity• Per: sonor/sonor• Aus: VBS simemetry, Rh -/-, Wh -/-

Thorax

• I: flat, lesion (-)• Aus: bowel sound (+) N• Pal: tenderness (+)• Per: timpany

Abdomen

• warm peripherals, no edema , no paralysisExtremities

Clinical Picture

Local Status

Head CT scan

Laboratory findings

• Hb : 11.5• WBC: 9.0• RBC: 3.67• Ht: 35• PLT: 229

• BSR: 141• PT/APTT: 13.4/25.1• SGOT/SGPT: 137/91• Ur/Cr: 64/1.1• Na/K/Cl: 140.2/4.0/106.0

Working diagnosis

Open fracture os femur sinistra + susp. Fracture basis cranii

Management

• Hospitalize• Laboratorium check• Ct scan• catheterization