Emergency Report 23-24

Emergency ReportOctober 23th – 24th 2014

Resident on Duty : dr Yan Aditya Chief : Iqbal

Coass on duty: Novita, Sindhu, Sari, Athira, Aditya, Riza, Ririn

Minor surgery :

Oncology surgery :

Digestive surgery :3

Thorax cardiovascular surgery :

Plastic surgery :

Urology surgery :

Neurosurgery : 2

Pediatric surgery :

Orthopedic : 4

Total : 9

PATIENT LIST

Patients ListNo Identity Admission to

E.R.Diagnosis Management

1 Mrs.Suratin

/64 y.o/1.12.52.82

October 23rd 2014/at 15.00

stroke hemorrhage with

ICH e/r temporoparietal

dextra 35 cc + IVH + hidrosephalus

acute

Observation of vital signHead up 30O2 10 lpmIVFD NS 20 gpmRanitidin 2x1Ketorolac 3x30 mgManitol 4x150 cc

Consult to Neurology Surgeon:- Craniotomy evacuation (cito)



2 Mrs.Norsyam

/47 y.o/1.12.52.85

October 23rd 2014/at 15.40

Stroke Hemorrhage with ICH at parietal sinistra (22,5 cc) +

Observation of vital signHead up 30O2 10 lpmIVFD NS 20 gpmRanitidin 2x1Ketorolac 3x30 mgManitol 4x150 cc

Consult to Neurology Surgeon:- Craniotomy evacuation



3 Mr. Chelsio/1.12.52.93/19 yo

23rd October 2014/17.40 WITA

Open fracture of digiti 5 phalang distal Vulnus laceratum and escoriatum e/r dorsum manus dextra

-Vital Sign observation-IVFD RL 20gtm-Antibiotic-ATS-Analgesic-H2 Blocker

-Consult to Orthopedic Surgeon

- Hospitalized- Pro cito debridement + ORIF

wire



4 Matnor/ 11 yo/1.12.58.57

23rd October 2014/ 19.00

Mild Head Injury (GCS 14)Closed fracture of tibia fibula dextra 1/3 distal tranverse displacmentClosed fracture of radius ulna sinistra 1/3 medial trranverse displacementClosed fracture of angulus mandibula dextra

Observation Vital SignAntibioticAnalgesicH2 BlockerO2

X-ray cervical skull, antebrachii, cruris

Consult to pllastic surgeon ORIF elective

Consult to orthopedic surgeonORIF elective



5 Mr. Ardiansyah/1.12.53.05/ 19 yo

23rd October 2014/ 21.00

Closed fracture of femur sinistra 1/3 medial transversal displacement Open fracture of patela sinistraFracture condillus mandibula bilateral

-Vital Sign observation-Antibiotic-Analgesic-H2 Blocker

-Consult to Orthopaedic Surgeon

- Hospitalized- ORIF elective- Skin traction

-Consult to plastic surgery - Orif elective



6 Mr. Yusri/1.12.53.04/25 yo

23rd October 2014/ 22.30

Close fracture of femur sinistra 1/3 medial comminutive displacement

-Vital Sign observation-Antibiotic-Analgesic-H2 Blocker

-Consult to Orthopaedic Surgeon

- Skin traction- Hospitalized- ORIF elective



7 Mrs. Mahsunah /24 yo/1.12.53.15

23th October 2014/ 23.30

Ileus obstructive partial et causa susp. Adhesive post op.

-Vital sign observation -IVFD RL 250 cc/day-Antibiotic-H2 blocker-Analgesic

Consult to digestive surgeon :HospitalizedFleet enema



8 Mr. Ridwan/1.12.53.14/37 yo

24th October 2014/ 02.00

Mild head injury

Fracture of simfisis mandibulla

Internal bleeding ec Abdomen blunt trauma

-Vital Sign observation-Head up 30 degree -O2 4 lpm canulle nasal-NS 20 gpm-Antibiotic-Analgesic-H2 Blocker-Tranexamat acid 3x500

-X-ray trauma series-Complete blood count

Consult to digestive SurgeonPro cito laparotomy

Consult to plastic SurgeonPro ORIF elective



8 Mr. Ridwan/1.12.53.14/37 yo

24th October 2014/ 02.00

Mild head injury

Fracture of simfisis mandibulla

Peritonitis due to Internal bleeding ec Abdomen blunt trauma

-Vital Sign observation-Head up 30 degree -O2 4 lpm canulle nasal-NS 20 gpm-Antibiotic-Analgesic-H2 Blocker-Tranexamat acid 3x500-NGT-DC-X-ray trauma series-Complete blood count

-Consult to nuero Surgery- Pro CT scan

Consult to digestive SurgeonPro cito laparotomy

Consult to plastic SurgeonPro ORIF elective



9 Mr. Suroto/ yo/1.12.53.15

24th October 2014/ 05.00

Peritonitis difuse due to acute mesenterial trombotic

-Vital sign observation -IVFD RL 20 gpm-Antibiotic-H2 blocker

-BNO 3 position-Complete blood count-Urinnalysa-NGT -DC

Consult to digestive surgeon :Pro laparotomy cito

• Chief Complain : decrease of consciousness• Since 5 days ago, patient suddenly get faint

when she doing her daily activity. She woke up, patient complain about vertigo and vomiting for several times. She feel weakness on her body. History of HT (+) more than 10 years. She then brought to the Pulang Pisau hospital and sent to Dorys hospital for CT scan. After CT scan, she was reffered to Ulin hospital for the advance therapy.

1. Mrs.Suratin/64 y.o/ October 23rd 20141.12.52.82/at 15.00

Physical Examination

Vital sign :• BP= 240/110 mmhg• HR = 96times/minute• RR = 22 times/minute• BT = 37ºC

• Head : Normochepal• Eyes : anemic conjunctivae(-/-), icteric sclerae (-/-)• Mouth : Moist mucous membrane• Neck : lymph nodes enlargement (-), JVP

enhancement (+)

Head/Neck

• I : symmetric respiratory movement, no retraction• P : symmetric VF• P : Sonor at all lung fields• A : symmetric VBS, no rhonchi, no wheezing,

crackles (-)

Chest

• I : excoriation (-)• P : H/L/M = no palpable, tenderness (-), rebound

tenderness (-), muscular rigidity (-)• P : tympanic• A : normal bowel sound

Abdomen

• Warm (+), no edema, no paralysis. Extremities

Clinical picture

Head CT Scan, October 24th 2014

Laboratory (23rd Oct 2014)Hasil Nilai Normal Satuan

Haemoglobin 13,6 14,0-18,0 g/dlWBC 11,0 4,0-10,5 Ribu/UlErythrocyte 4,80 3,90-5,50 Juta/UlHematocrit 41,5 42,00-52,00 Vol%Platelet 242 150-450 Ribu/UlRDW-CV 13,7 11,5-14,7 %MCV 86,6 80,0-97,0 FlMCH 28,3 27,0-32,0 PgMCHC 32,7 32,0-38,0 %

Laboratory (23rd Oct 2014)

HASIL NILAI NORMAL

SATUAN

Gran% 78,4 50,0-70,0 %Limfosit% 13,8 25,0-40,0 %MID% 7,8 4,0-11,0 %Gran# 8,60 2,50-7,00 ribu/ulLimfosit# 1,5 1,25-4,0 ribu/ulMID# 0,9 ribu/ul

HASIL NILAI NORMAL

SATUAN

Natrium 142,2 135-146 mmol/lKalium 3,9 3,4-5,4 mmol/lChloride 105,3 95-100 mmol/lPT 9,2APTT 11,4Blood glucose 149 <200 mg/dlSGOT 26 0-46 U/ISGPT 21 0-45 U/I

3,5-5,5Ureum 66 10-50 mg/dlCreatinine 1,1 0,7-1,4 mg/dl

2,4-5,7


Working Diagnosis

• stroke hemorrhage + ICH e/r temporoparietal dextra 35 cc + IVH + hidrosephalus acute

ManagementObservation of vital signHead up 30O2 10lpm nasalIVFD NS Ranitidin 2x1Ketorolac 3x30 mgManitol 4x150 cc

Consult to Neurology Surgeon:

- Craniotomy evacuation (cito)

BACK

• Chief Complain : Weakness on the right extremities

• Since 1 week before admission,she got faint when did her daily activity. When she woke up, she vomited once and fell weakness at all her right extremities and cannot speak well. She then hospitalized at Islam hospital and got CT Scan, then referred brought to Ulin hospital. History of hipertension (+) for 5 years , history of diabetic unknown.

2. Mrs.Norsyam/47 y.o/ October 23rd 20141.12.52.85/at 15.40

Physical Examination

Vital sign :• BP= 160/110 mmhg• HR = 72times/minute• RR = 22 times/minute• BT = 37ºC

• Head : Normochepal• Eyes : anemic conjunctivae(-/-), icteric sclerae (-/-)• Mouth : Moist mucous membrane• Neck : lymph nodes enlargement (-), JVP

enhancement (+)

Head/Neck

• I : symmetric respiratory movement, no retraction• P : symmetric VF• P : Sonor at all lung fields• A : symmetric VBS, no rhonchi, no wheezing,

crackles (-)

Chest

• I : excoriation (-)• P : H/L/M = no palpable, tenderness (-), rebound

tenderness (-), muscular rigidity (-)• P : tympanic• A : normal bowel sound

Abdomen

• Warm (+), no edema, no paralysis. Extremities

Clinical picture

CT Scan October 23rd 2014




HASIL NILAI NORMAL

SATUAN


HASIL NILAI NORMAL

SATUAN

Natrium 139,0 135-146 mmol/lKalium 4,2 3,4-5,4 mmol/lChloride 101,2 95-100 mmol/lPT 10,1APTT 23,9Blood glucose 75 <200 mg/dlSGOT 28 0-46 U/ISGPT 16 0-45 U/IAlbumin 4,0 3,5-5,5Ureum 30 10-50 mg/dlCreatinine 0,6 0,7-1,4 mg/dlUric Acid 2,4 2,4-5,7


Working Diagnosis

• SH+ ICH at parietal sinistra (22,5 cc)

ManagementObservation of vital

signHead up 300

O2 4lpm nasalManitol 4x100 ccRanitidin 2x1Ketorolac 3x30 mg

Consult to Neurology Surgeon:

- Craniotomy evacuation (cito)

BACK

3. Mr. Chelsio/1.12.52.93/19 yo/23rd October 2014/17.40 WITA

Chief complain: Open wound on the right handHalf an hour before admission when patient at the

firefighter car, the car rolled because avoiding a bus, after crash the car roll over. The window didn’t close and his hand wedge on the window and suppressed by car. Faint (-), nose/mouth/ear bleeding (-), he got bleeding from his finger and its pain to move, then he brought to the ULIN hospital by his friends.

Primary Survey

• Clear (+), snoring (-), gurgling(-), c-spine control A• Clear, RR : 20 x/mt, symmetric respiratory movement,

VBS equalB• BP: 110/80 mmHg, Pulse 82 x/mnt ,reguler, strong

pulsation.C• GCS 15 E4V5M6, Pupil equal 3mm/3mm, no paresis, Brille

Haematoma -/-, Bloody Rinorrhae -/-, Bloody Otorrhae -/-, Battle’s sign -/-D

• (-)A• (-)M• (-)P• 2 Hours before admissionL• On the streetE

Secondary Survey• Eyes : anemic conjunctivae (-/-), icteric sclerae (-), • Nose : 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 : distended (-)• A : normal Bowel sound • P : Liver/spleen/kidney not palpable, mass palpable,

tenderness (-) , rebound tenderness (-)• P : Tympanic

Abdomen

• No parese, no oedem, scars (-),Extremities

Secondary Survey

• L : Open wound at 5th finger with bone exposed• F : Pressure pain (+), crepitation.(+)• M : ROM limited cause of pain

Et regio manus dextra

(digiti 5)

• L : Open wound muscle based about 10 cm• F : Crepitation (-)• M : ROM normal

Et regio dorsum manus

dextra

Clinical Picture

Clinical Picture

• L : Open wound at 5th finger with bone exposed

• F : Pressure pain (+), crepitation.(+)• M : ROM limited cause of pain

Et regio manus dextra (digiti 5)

Clinical Picture

• L : Open wound soft tissue based about 10 x 1 cm, escoriation

(+)• F : Crepitation (-)• M : ROM normal

Et regio dorsum manus dextra

X-Ray 23rd October 2014




HASIL NILAI NORMAL

SATUAN


HASIL NILAI NORMAL

SATUAN

Natrium 138,3 135-146 mmol/lKalium 3,9 3,4-5,4 mmol/lChloride 100,8 95-100 mmol/lPT 11,7APTT 28,1Blood glucose 101 <200 mg/dlSGOT 38 0-46 U/ISGPT 35 0-45 U/I


2,4-5,7


Working Diagnosis

• Open fracture of digiti 5 phalang distal • Vulnus laceratum and escoriatum e/r dorsum manus dextra

Management- Vital Sign

observation- IVFD RL 20gtm- Antibiotic- Analgesic- ATS- H2 Blocker

- Consult to Orthopedic Surgeon- Hospitalized- Pro cito debridement

+ ORIF wire

BACK

4. Matnor/ 11 yo/1.12.58.57/ 23rd October 2014/ 19.00

Chief complaint: Pain on the arms and legs3 hours before admission, patient hit by motorcycle at

handil bakti when he cross the road. He hit by the motorcycle from the right side. He threw far about 1 meter. Hystory of faint (+) . There’s no history of nose/mouth/ear bleeding, after woke from his faint patient feel very pain at his arms and legs, and cannot walk. He then brought by people to the emergency unit at Anshari Saleh hospital and get simple fixation for his arm and leg, after that she referenced to Ulin hospital for further therapy.

Primary Survey

• Clear (+), snoring (-), gurgling(-), c-spine control A• Clear, RR : 22x/mt, symmetric respiratory movement,

VBS equal, Rh(-/-), Wh (-/-)B• Pulse 85 x/mnt ,reguler, strong pulsation.C• GCS 14 E3V5M6, Pupil equal 2mm/2mm, no paresis, Brille


• (-)A• (-)M• (-)P• 2 hours before admissionL• On the roadE

Secondary Survey• Eyes : anemic conjunctivae (-/-), icteric sclerae (-),• Nose : epistaxis (-)• Mouth : wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck


Chest

• I : distended (-). Et regio pelvic lesion (-)• A : normal Bowel sound • P : Liver/spleen/kidney not palpable• P : Tympanic

Abdomen

• No parese, no oedem, Extremities

Secondary Survey

• L : deform (+), swelling (+)• F : Crepitation (+), Pressure pain (+)• M : ROM limited because of pain

Et regio mandibula

dextra

• L : deform (+), swelling (+)• F : crepitation (+), Pressure pain (+), A. Radialis pulse

(+)• M : ROM limited because of pain

Et regio antebrachii

sinistra

• L : deform (+), swelling (+)• F : Pressure pain (+), crepitation (+), A. dorsalis pedis

(+)• M : False movement (+)

Et regio cruris dextra

Clinical Picture

Status localize

• L : deform (+), swelling (+), sutured wound 3cm lenght• F : Crepitation (+), Pressure pain (+)• M : ROM limited because of pain

Et regio mandibula dextra

Status localize

• L : deform (+), swelling (+)

• F : crepitation (+), Pressure pain (+), A. Radialis pulse (+)

• M : ROM limited because of pain

Et regio antebrachii sinistra

Status localize

• L : deform (+), swelling (+)

• F : Pressure pain (+), crepitation (+), A. dorsalis pedis (+)

• M : False movement (+)

Et regio cruris dextra

X Ray October 23rd 2014

CT Scan October 23rd 2014




HASIL NILAI NORMAL

SATUAN


Laboratory October 23rd 2014HASIL NILAI

NORMALSATUAN

PT 12,6APTT 28,4Blood glucose 249 <200 mg/dlSGOT 145 0-46 U/ISGPT 48 0-45 U/I


Working Diagnosis

• Mild Head Injury (GCS 14)• Closed fracture of tibia fibula dextra 1/3 distal tranverse

displacment• Closed fracture of radius ulna sinistra 1/3 medial tranverse

displacement• Closed fracture angulus mandibula dekstra

Management• Observation Vital

Sign• Antibiotic• Analgesic• H2 Blocker• Oxygenation

• X-ray cervical skull, antebrachii, cruris

Consult to plastic surgeon• ORIF elective

Consult to orthopedic surgeon• ORIF elective

BACK

5. Mr. Ardiansyah/1.12.53.05/19 yo/23rd October 2014/ 21.00

Chief complain: Pain and wound at the left leg3 hours before admission patient had a crash with a

motorcycle from the opposite direction in martapura. He wore Helmet (+), he fall and his leg was hit by motorcycle. Faint (+), nose/eye/mouth bleeding (-). He feel pain on the leg, bleeding and pain when it be moved. He also feel pain on his jaw. And his jaw cant be close well He then brought to the Martapura hospital and referenced to Ulin hospital.

Primary Survey





• (-)A• ATSM• (-)P• 7 Hours before admissionL• On the streetE


Head/Neck


Chest

• I : distended (-)• A : normal Bowel sound • P : Liver/spleen/kidney not palpable, mass palpable,


Abdomen

• No parese, no oedem, scars (-),Extremities

Secondary Survey

• L : Deform (+)• F : Pressure pain (+), crepitation.(+)• M : ROM mandibula limited

Et regio Mandibula

dextra sinistra

• L : Sutured wound (+) about 1 cm• F : Crepitation (+), Pressure pain (+), A.dorsalis

pedis (+)• M : False movement (+), ROM limited (+)

Et regio femur sinistra

• L : Sutured wound 10 cm • F : Crepitation (+), pressure pain (+), A.Dorsalis pedis

(+)• M : False movement (-), ROM limited d

Et genu tibia sinistra

Clinical Picture

Clinical Picture Et regio mandibula

L : Deform (+), mal oclusion (+)F : Pressure pain (+), crepitation.(+)M : ROM mandibula limited

Clinical Picture

Et regio femur sinistra

L : Sutured wound (+) about 1 cmF : Crepitation (+), Pressure pain (+), A.dorsalis pedis (+)M : False movement (+), ROM limited (+)

Clinical Picture

Et regio genue sinistra

L : Sutured wound 10 cm F : Crepitation (+), pressure pain (+), A.Dorsalis pedis (+)M : False movement (-), ROM limited







HASIL NILAI NORMAL

SATUAN



NORMALSATUAN

INR 1,02PT 11,6APTT 24,5Blood glucose 192 <200 mg/dlSGOT 71 0-46 U/ISGPT 34 0-45 U/IAlbumin 3,5-5,5Ureum 23 10-50 mg/dlCreatinine 0,9 0,7-1,4 mg/dl

Working Diagnosis

• Closed fracture of femur sinistra 1/3 medial transversal displacement

• Open fracture pattela sinistra• Fracture condillus mandibula bilateral


observation- Antibiotic- Analgesic- H2 Blocker

- Consult to Orthopaedic Surgeon- Hospitalized- debrideman- ORIF elective

BACK

6. Mr. Yusri/1.12.53.04/25 yo/23rd October 2014/ 22.30

Chief complain: Pain on the left leg1 day before admission patient had been fallen when he

ride motorcycle. His motorcycle crashed the tree and he fall with the left leg hit ground first. Helmet (+). Faint (-), nose/mouth/ear bleeding (-). After that accident, he feel his pain on his leg and its pain to be move. Then, he took to Tanah Bumbu hospital by friends. He did x-ray photo and got medication. Patient referenced to Ulin hospital for advance therapy.

Primary Survey





• (-)A• Ranitidin, ketorolacM• (-)P• 4 Hours before admissionL• On the streetE


Head/Neck


Chest

• I : distention (-)• A : normal Bowel sound • P : Liver/spleen/kidney not palpable, mass palpable,


Abdomen

• No parese, no oedem, scarsExtremities

• L : Deform (+), swelling (+)• F : crepitation (+), Pressure pain (+), a.dorsalis pedis (+)• M : ROM limited because of pain, false movement (+)

Et Regio femur sinistra

Clinical Picture

Clinical Picture

• L : Deform (+), swelling (+)• F : crepitation (+), Pressure pain (+), a.dorsalis pedis (+)• M : ROM limited because of pain, false movement (+)

Et Regio femur sinistra

X-Ray 22nd October 2014 (At tanah bumbu hospital)

X-Ray 22nd October 2014 (At tanah bumbu hospital)


Haemoglobin 11,9 14,0-18,0 g/dlWBC 9,5 4,0-10,5 Ribu/UlErythrocyte 4,62 3,90-5,50 Juta/UlHematocrite 37,7 42,00-52,00 Vol%Platelet 150 150-450 Ribu/UlRDW-CV 13,6 11,5-14,7 %MCV 81,8 80,0-97,0 FlMCH 25,7 27,0-32,0 PgMCHC 31,5 32,0-38,0 %


HASIL NILAI NORMAL

SATUAN



NORMALSATUAN

Natrium 136,8 135-146 mmol/lKalium 3,6 3,4-5,4 mmol/lChloride 102,0 95-100 mmol/lPT 11,3 9,9-13,5APTT 25,9 22,2-37,0Blood glucose 140 <200 mg/dlSGOT 54 0-46 U/ISGPT 30 0-45 U/I


2,4-5,7

Working Diagnosis

• Close fracture of femur sinistra 1/3 medial comminutive displacement


observation- Analgesic- H2 Blocker

- Consult to Orthopaedic Surgeon- Skin traction- Hospitalized- ORIF elective

BACK

7. Mrs. Mahsunah /24 yo/1.12.53.15/23th October 2014/ 23.30

Chief complain: distention stomach One day before admission patient feel her stomach

distended and she cant defecated but stil fart. Vomit (+), 4 days before admission she has a history of caesarean section surgery because of fetal distress at Martapura hospital. After that surgery she can’t defecate but still fart. When she was at her 6 months pregnancy, she diagnosed had appendicitis. There’s no history bloody feces before. History of watery feces 2 days before admission, but he didn’t take any medication and then she brought to Ulin hospital because of her complain.

Vital Sign• GCS : E4V5M6

• TD : 120/70 mmHg• HR : 84 times/minutes• RR : 20 times/minutes• Temp : 36,6 °C

General Examination• Eyes : anemic conjunctivae (-/-), icteric sclerae (-), • Nose : epistaxis (-)• Mouth : wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck

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

Chest

• I : distention (+). Wound of SC surgery (+), clean and sutured, pus (-)

• A : metallic sound (+), bowel sound (+)• P : Liver/spleen/kidney not palpable• P : Tympanic

Abdomen

• Warm (+), No parese, no oedem, scars (-)Extremities

Rectal touche• Spincter Ani Tone : strong• Collapse ampulla (-)• Pressure pain (-)• Massa (-)• Feces (+), blood (-)

Clinical Picture

Status localize Abdomen : distention (+). Wound of SC surgery (+), clean and sutured, pus (-)

Auscultation : metallic sound (+),

X-ray (BNO 3 positions) 24th October 2014

Laboratory (24th Oct 2014)Hasil Nilai Normal Satuan

Haemoglobin 8,0 14,0-18,0 g/dlWBC 15,7 4,0-10,5 Ribu/UlErythrocyte 3,40 3,90-5,50 Juta/UlHematocrit 27 42,00-52,00 Vol%Platelet 351 150-450 Ribu/UlRDW-CV 17,3 11,5-14,7 %MCV 79,5 80,0-97,0 FlMCH 23,5 27,0-32,0 PgMCHC 29,6 32,0-38,0 %

Laboratory (24th Oct 2014)

Result Normal score UnitGran% 81,9 50,0-70,0 %Limfosit% 10,9 25,0-40,0 %MID% 7,2 4,0-11,0 %Gran# 12,90 2,50-7,00 ribu/ulLimfosit# 1,7 1,25-4,0 ribu/ulMID# 1,1 ribu/ul

Laboratory October 24th 2014HASIL NILAI

NORMALSATUAN

Natrium 132,8 135-146 mmol/lKalium 3,6 3,4-5,4 mmol/lChloride 103,5 95-100 mmol/lPT 9,7 9,9-13,5APTT 26,1 22,2-37,0Blood glucose 113 <200 mg/dlSGOT 28 0-46 U/ISGPT 11 0-45 U/I

Ureum 24 10-50 mg/dlCreatinine 0,6 0,7-1,4 mg/dl

Working Diagnosis

Ileus obstructive partial et causa susp. Adhesive post op.

Management

- Vital sign observation

- IVFD RL Antibiotic

- H2 blocker- Analgesic

Consult to digestive surgeon :

• Hospitalized• Fleet enema

BACK

8. Mr. Ridwan/1.12.53.14/37 yo/24th October 2014/ 02.00

Chief complain: abdominal pain1 hours before admission patient ride a motorcycle while

drunk. He didn’t use helmet and crash an street devider around Banjarbaru. Mechanism of trauma is unknown. and got faint, nose/mouth/ear bleeding (+/+/-), and his jaw are broken. he was brought to Banjarbaru hospital by civilian and then referenced to Ulin hospital. After he woke up. He feel his stomach pain

Primary Survey




Haematoma (+), Light reflex +/+D

• (-)A• (-)M• (-)P• 1 Hours before admissionL• On the streetE

General Examination• Eyes : anemic conjunctivae (-/-), icteric sclerae (-), • Nose : epistaxis (+)• Mouth : deformity at lower jaw (+) mal oklusion (+)• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck


Chest

• I : distention (-). • A : metallic sound (-), bowel sound (+) decreased• P : Liver/spleen/kidney not palpable, tenderness (+)• P : Tympanic

Abdomen


Rectal touche• Normal Spincter ani tone • Collapse ampulla(-)• Mass (-)• Pressure pain (+)• Feces (+), blood (-)

Clinical Picture

Clinical Picture

• Brill haematome +/+

Et regio periorbita

• L :Deform (+),• F : Crepitation (+),

step defect (+)• M : False movement

(+), ROM limited (+)

Et regio mandibula

X-Ray 24th October 2014



HASIL NILAI NORMAL

SATUAN




NORMALSATUAN

Natrium 144,6 135-146 mmol/lKalium 4,2 3,4-5,4 mmol/lChloride 108 95-100 mmol/lPT 13,3 9,9-13,5APTT 25,3 22,2-37,0Blood glucose 133 <200 mg/dlSGOT 625 0-46 U/ISGPT 375 0-45 U/I


Working Diagnosis

• Mild head injury• Fracture of simfisis mandibulla• Peritonitis due to Internal bleeding ec Abdomen blunt trauma

Management- Vital Sign observation- Head up 30 degree - O2 4 lpm canulle nasal- NS 20 gpm- Antibiotic- Analgesic- H2 Blocker- Tranexamat acid 3x500- NGT- DC- X-ray trauma series- Complete blood count

- Consult to nuero Surgery- Pro CT scan

- Consult to digestive Surgeon- Pro cito laparotomy

- Consult to plastic Surgeon- Pro ORIF elective

BACK

9. Mr. Suroto/ yo/1.12.53.15/24th October 2014/ 05.00

Chief complain: Can’t defecate1 day before admission patient complain that he can’t

defecate and fart, his stomach distention and pain, there’s no history of watery feces or bloody feces. Patien also complain vomiting after he take a meal. The pain start since 3 days ago arround umbilical and than spread to whole abdominal. The pain getting worst each day especialy after eat. No history of herbal or analgetic daily compsumption before. No history of loss body weight. No hystory of fever. Hystory of HT (+)more than 5 years hystory of DM is unknown

Vital Sign• GCS : E4V5M6

• TD : 160/100 mmHg• HR : 90 times/minutes• RR : 20 times/minutes• Temp : 37 °C

General Examination• Head : Normochepal• Eyes : anemic conjunctivae (-/-), icteric sclerae (-), • Nose : epistaxis (-)• Mouth : wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck


Chest

• I : distention (-). • A : bowel sound (+)• P : Liver/spleen/kidney not palpable. Pressure pain (+),

rebound tenderness (+)• P: Tympanic

Abdomen


Rectal touche• Spincter Ani Tone : strong• Smooth mucosa• Collapse ampulla (-)• Pressure pain (+) at 9-3 o’clock• Massa (-)• Feces (+), blood (-)

Clinical Picture

Status localize

• I : distention (+). • A : bowel sound (+) decreased• P : Liver/spleen/kidney not

palpable. Pressure pain (+), rebound tenderness (+)

• P: Tympanic

Abdomen

X Ray 24th October 2014

X Ray 24th October 2014


Haemoglobin 18,0 14,0-18,0 g/dlWBC 19,2 4,0-10,5 Ribu/UlErythrocyte 6,10 3,90-5,50 Juta/UlHematocrit 52 42,00-52,00 Vol%Platelet 263 150-450 Ribu/UlRDW-CV 13,4 11,5-14,7 %MCV 85,3 80,0-97,0 FlMCH 29,5 27,0-32,0 PgMCHC 34,6 32,0-38,0 %


Result Normal score UnitGran% 84,7 50,0-70,0 %Limfosit% 9,7 25,0-40,0 %MID% 5,6 4,0-11,0 %Gran# 16,30 2,50-7,00 ribu/ulLimfosit# 1,9 1,25-4,0 ribu/ulMID# 1 ribu/ul


NORMALSATUAN

Natrium 137,5 135-146 mmol/lKalium 3,5 3,4-5,4 mmol/lChloride 101,9 95-100 mmol/l

Blood glucose 311 <200 mg/dlSGOT 33 0-46 U/ISGPT 23 0-45 U/I


Urinalisa (October 24th 2014)

HASIL NILAI NORMAL

SATUAN

Color Yellowish-clear Yellowish-clear

pH 5.0 5,0-6,5Keton Negative NegativeProtein-albumin Trace NegativeGlucose 4+ NegativeBilirubin Negative NegativeBlood smear Negative NegativeNitrit Negative NegativeUrobilinogen 0,2 0.1-1.0WBC Negative Negative

HASIL NILAI NORMAL

SATUAN

WBC 0-1 0-3Eritrocyte 0-1 0-2Cilinder Negative Negative Epitel 1+ 1+Bacteri Negative Negative Kristal Negative NegativeLain-lain Negative Negative

Urinalisa (October 24th 2014)

Working Diagnosis

. Peritonitis difuse due to acute mesenterial trombotic

Management- Vital sign

observation - IVFD RL 20 gpm- Antibiotic- H2 blocker

- BNO 3 position- Complete blood

count- Urinnalysa- NGT - DC

Consult to digestive surgeon :

• Pro laparotomy cito

BACK

THANKS!

Documents

Emergency Report 23-24