Lap Jag 24

Emergency ReportMay 24th - 25th, 2014

Co-Ass on duty: Redha, Fath, Ferisa, Shinta, Fatimah, Sari

Resident on duty:Dr. Andika August Winata

Chief on duty:Zainul Muttaqien

Oncology surgery : -

Digestive surgery : 1

Thorax cardiovascular surgery :

Plastic surgery :

Urology surgery : -

Neurosurgery : -

Pediatric surgery : -

Orthopedic : 1

Total : 3

PATIENT LIST

Patients ListNo Identity Admission to

E.R.Diagnosis Management

1. Siti Mahdalena/ 54 yo/ 111.02.77

24th June 2014/ 14.30

Anterior Dislocation of the right Shoulder Joint

Observation Vital SignAnalgeticH2 Blocker

Consult to Orthopaedic SurgeonClosed Reduction

2. Arbain/ 33 yo/ 11.02.95

24th june 2014/ 19.35

Peritonitis diffuse ec abcess hepar rupture

IVFD NSAntibioticAnalgeticH2 BlockerComplete Lab CheckThorax and BNO rontgenDCNGTFluid Balance



3. Herman/ 74 yo/ 11.02.96

24th June 2014/ 20.35

Tetanus Phillips score 12 (moderate)Ablett grade III-IV

IVFD RL : D5NGTTetanus Immunoglobulin 3000 IU multi siteAntibioticH2 BlockerDiazepam dripHospitalized

Autonomic Storm 23.00Consult InternistHospitalized ICUDiltiazemMidazolam drip



4. Bidin/ 47 yo/ 111.02.94

24th June 2014/ 18.55

1. Siti Mahdalena/ 54 yo/ 24th June 2014/ 14.30Chief complain: Pain at right shoulder History : 2 hours before admission, when patient rode

motorcycle in a slippery road, suddenly she fell on her own. She fell with her right hand hit the ground first. After the accident, she felt pain in her left shoulder, and she went to masseur, but her complaint didn’t gone.

List of patient

Primary Survey

• clear, snoring (-) gurgling (-) C-spine control A

• RR : 18/mt, simmetry respiratory movement, VBS simmetry, Rh (-), Wh (-)B

• Pulse 80 t/mt,reguler, lift strong, regular• BP: 120/80 mmHg C• GCS E4V5M6 =15, Pupil 3mm/3mm, light

reflex +/+, DList of patient

A -

M -

P -

L 4 Hour before admission

E On the road

List of patient

Physical Examination• 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 field• A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)

Chest

• I : distention (-), mass (-),• A : Bowel sound (+)• P : Abdominal pain (-), mass (-)• P : Tympani

Abdomen

• Warm, edema (-/-), parese (-/-)Extremities

List of patient

Clinical picture

List of patient

Clinical Picture

Laboratory Findings• Hb : 12,9• WBC : 13,7• RBC : 4,54• Hematocrite : 38,1• Plt : 260• PT/APTT : 9,3/19,3• BSN : 173• SGOT/SGPT : 68/56• Ur/Cr : 17/0,74

• Na : 141,8• K : 5,09• Cl : 105,6

List of patient

Thorax AP 24th June 2014

Shoulder X-Ray 24 June 2014

Shoulder X-Ray Post Reduction

Working Diagnosis

Anterior Dislocation of the right Shoulder Joint

List of patient

Management• Observation Vital Sign• Analgetic• H2 Blocker

Consult to Orthopaedic Surgeon• Closed Reduction

2. Arbain/ 33 yo/ 24th June 2014/ 19.35

Chief complain: pain in stomach History : 5 days before admission, patient complaint that his

stomach getting bigger and he felt pain in his abdomen. Pain start on his upper right abdomen, intermitten, and not spreading to the back. 2 weeks before admission, he had bloody and mucous diarrhea, and felt pain when he defecate, he also had intermitten fever. He also vomiting, 2 times, yellow colored, and his body become yellow (jaundice). No history of trauma, no history of jaundice.

Occupation : merchantHistory of smoke cigarette : 2 packs a dayAlcoholism (+)

List of patient

Vital Sign

• GCS : E4V5M6• HR : 104 x/minutes• BP : 110/80 mmHg• RR : 24 x/minutes• T : 36,9⁰C

Physical Examination

• Eyes : Anemic conjunctivae (-), icteric sclerae (+/+), • Nose : epistaxis (-)• Mouth : Wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck


Chest

• I : distention (+), mass (-), • A : Bowel sound (-)• P : Abdominal pain (+), defans muscular (+)• P : Hypertympani

Abdomen

• Warm, edema (-/-), parese (-/-)Extremities

List of patient

Clinical picture

List of patient

Clinical Picture

• Insp :Distended, mass (-)• Ausc: Bowel sound (-)• Palp :Pain (+), defans

muscular (+)• Perk :Hypertympani

Rectal Toucher• Mass (-)• Strong TSA, ampulla not collapse• Slippery mucose• Prostat palpable, 2 bread finger, nodule (-)• Handscoen : mucous (-), blood (-), feces (-)

Laboratory Findings 24th June 2014

• Hb : 12,8• WBC : 29,8• RBC : 40,4• Hematocrite : 38,1• Plt : 709• PT/APTT : 15,3/25,2• BSN : 103• SGOT/SGPT :

43/40• Ur/Cr : 34/0,76

• Bilirubin• Total : 1,85• Direct : 1,80• Indirect : 0,05

• Na : 135,0• K : 4,67• Cl : 99,7

List of patient

Thorax X-Ray 24 June 2014

BNO 3 Position 24th June 2014

BNO 3 Position 24th June 2014

Working Diagnosis

Peritonitis diffuse ec abcess hepar rupture

List of patient

Management• IVFD NS• Antibiotic• Analgetic• H2 Blocker• Complete Lab Check• Thorax and BNO rontgen• DC• NGT• Fluid Balance

3. Herman/ 74 yo/ 24th June 2014/ 20.35 Chief complain: stiffness in mouthHistory : 2 weeks before admission, patient had wound in

his foot, after he fell down and his foot hit the stone, his foot got lacerated wound. He didn’t wash his wound, and this morning he felt stiffness in his mouth when he try to open it. There is no stiffness in stomatch, sweating, and hard to breath. No abnormality in defecate and urinate.

List of patient

Vital Sign

• GCS : E4V5M6

• HR : 88 x/minutes• RR : 22 x/minutes• BP : 170/100 mmHg• T : 36,7⁰C


• Eyes : Anemic conjunctivae (-), icteric sclerae (-/-), • Nose : epistaxis (-)• Mouth : Wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement

(-)

Head/Neck


Chest

• I : distention (-), mass (-), • A : Bowel sound (+)• P : Abdominal pain (-), defans muscular (-) Epistotonus (-)• P : Tympani

Abdomen

• Warm, edema (-/-), parese (-/-) Spastic (-/-)Extremities

List of patient

Clinical picture

List of patient

Clinical Picture

• Insp :Distended, mass (-)• Ausc: Bowel sound (-)• Palp :Pain (+), defans

muscular (+)• Perk :Hypertympani

Autonomic Storm, 23.00

• HR : 190• RR : 22• TD : 200/100


• Hb : 14,6• WBC : 6,9• RBC : 5,42• Hematocrite : 44,8• Plt : 291• PT/APTT : 11,4/21,3

List of patient

Working Diagnosis

Tetanus Phillips score 12 (moderate)Ablett grade III - IV

List of patient

Management

• IVFD RL : D5• NGT• Tetanus Immunoglobulin 3000 IU multi site• Antibiotic• H2 Blocker• Diazepam drip• HospitalizedAutonomic Storm 23.00• Consult Internist• Hospitalized ICU• Diltiazem• Midazolam drip

4. Bidin 47 yo/ 24th june 2014/ 18.55 Chief complain: History :

List of patient

Vital Sign

• GCS : E3V5M6

• HR : 94 x/minutes• RR : 28 x/minutes• BP : 180/100 mmHg• T : 36,9⁰C


• Eyes : Anemic conjunctivae (-), icteric sclerae (-/-), • Nose : epistaxis (-)• Mouth : Wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement

(-)

Head/Neck


Chest

• I : distention (-), mass (-), • A : Bowel sound (+)• P : Abdominal pain (-), defans muscular (-)• P : Tympani

Abdomen

• Warm, edema (-/-), parese (-/-) Extremities

List of patient

Clinical picture

List of patient


• Hb : 16.0• WBC : 11,4• RBC : 5,40• Hematocrite : 48,7• Plt : 230• PT/APTT : • BSN : 136• SGOT/SGPT :

26/26• Ur/Cr : 38/1,01

• Na : 141,5• K : 3,52• Cl : 101,4

List of patient

Thorax AP 24th June 2014

CT Scan 24th June 2014

CT Scan 24th June 2014

Working Diagnosis

List of patient

Management

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Lap Jag 24