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NoIdentityAdmission to E.R.DiagnosisTreatment / Planning1

Miss. Sutarni/15 y.o/1-14-36-66

15March 2015/ 07.15 am

Dislocation manubrium clavicula sinistraTramadol 3x1Ketorolac 3x1Ranitidin 2x1

Co. Ortho :X-Ray Thorax AP/PAX-Ray Shoulder AP sin


Miss. Nada Lestari /18 y.o/ 1.14.36.65

15 March 2015/ 05.30 am

Mild Head Injury (GCS 14 E3M6V5) + VL a/r parietal dextra et sinistraObs.vital signHead up 30O2 masker 6 LpmHead ct scan


Mr. Sadri/ 40 y.o/ 1.14.36.68

15 March 2015/ 09.20 am

Mild head injury GCS 14 (E3M6V5) + susp. Fraktur basis cranii + SAH + SDH a/r frontal dextra + open fracture of left + tibia distal 3rd obliq displaced + open fraktur of left calcacal + closed fracture of left fibula dextraObs vital signIVFD RL 20 tpmDCO2 6 Lpm maskerInj ceftriaxon 2x1 gInj Ranitidin 2x1 ampInj Ketorolac 2x30mgTranexamat acid 3x200mgX-ray cruris AP/LatX-Ray manus sin AP/lat Co Sp.OT :ImobilisationPro ORIF


Mr. Hardiman/ 49 y.o/ 1.14.36.84

15 March 2015/ 17.00 pmMild head injury GCS 15 + ICH a/r frontalis dextra 10cc + open fraktur os frontalis dextraObs vital signX-ray skull AP/latHead ct scan Wound toiletHectingIVFD RL 20 tpmKetorolac 3x30 mgRanitidin 2x1 ampCeftriaxon 2x1 grOndancentron 3x4 mg

Co neuro surgery :Pro craniotomy


Mrs. Nor Asiah/ 32 y.o/ 1-14-36.-1

15 March 2015/ 10.55 am

VE a/r manus Trombopop gelMeloxicam 2x1


Mr. Nasrudin/ 50 y.o/ 0.72.62.05

15 March 2015/ 14.30 pm

Vulnus laceratum et regio digitimanus IV sinistraWound toiletHectingATSCefodroxil 2x1Mefenamat acid 3x4


Miss. Sopia/ 13 y.o/ 1.14.36.72

15 March 2015/ 14.30 pm

VL a/r pedis dextraWound toiletPrimarry sutureATSMefenamat acid 3x1Ciprofloxacin 2x1Ranitidin 2x1


Mrs. Jumah/ 51 y.o/ 1.14.36.91

15 March 2015/ 23.30 pm

Obs dispneu ec susp tumor laringObs vital signO2Inj. Ceftriaxon 2x1 gInj. Dexametason 3x1 ampInj. Ranitidin 2x1 amp

Co. onko :Pro tracheostomy


Mr. Nur Khalis/ 22 y.o/ 1.14.37.01

16 March 2015/ 03.10 am

Mild head injury GCS E4V5M6O2Head up 30IVFD RLInj. Ketorolac 3x30 mgInj. Ranitidin 2x50 mgInj. Ceftriaxon 2x1 ampCt scanLab complete

Miss. Suratmi/ 15 y.o/ 1.14.36.66 14th March 2015/ 07.15 am

Chief Complain : left hand hard driven History : 1o hour before admission patient had been accident with motor cycle in Sampit, patient snagged cable on the road. The cable stuck in the her neck. Helm (+), the patient bounching to the street. unconscious (-) nausea-vomitting (-), bleeding nose / mouth / ear ( -/-/-). Pain on the left shoulder and the left hand. Crowded (-) Pain on the neck (-). The patient taken to the hospital Sampit and then taken to the hospital Ulin Banjarmasin .

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Primary Survey

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General Status

A-M-P-L10 hours before admissionEOn the road

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Clinical Picture

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Local Status

a/r shoulder sinistra :L = edem (-) deformity (-)F = crepitation (-), tenderness (-)M= limited due to pain

X-ray

Working Diagnosis

Dislocation manubrium clavicula sinistra

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Management

Tramadol 3x1Ketorolac 3x1Ranitidin 2x1

Co. Ortho :X-Ray Thorax AP/PAX-Ray Shoulder AP sinArm sling

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Miss. Nada Lestari/ 18 y.o/ 1.14.36.65 15th March 2015/ 05.30 amChief Complain : UnconsciousnessHistory : 2 hours before admission the patient had a accident motorcycle in Martapura, with mild speed and be hit by another motorcycle. Helm (+), patient fell to the aspalt and struck her head. Unconscious (+) nausea-vomitting (-), bleeding nose / mouth / ear ( - / - / -). Headache (+). The patient taken to the Central hospital Martapura and then taken to the hospital Ulin Banjarmasin .

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Primary Survey

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General Status

A-M-P-L2 hours before admissionEOn the road

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Clinical Picture

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Localized status

a/r parietal dextra :L = open wound x cmF = pain (+) crepitation (-)M = ROM (-)

a/r parietal sinistra :L = open wound x cm tepi irregularF = pain (+) crepitation (-)M = -

Working DiagnosisMild Head injury (GCS 14 E3M6V5) + VL a/r parietal dextra et sinistra

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Management

Obs. Vital signHead up 30O2 masker 6 LpmCt Scan head

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Mr. Sadri/ 40 y.o/ 1.14.36.68 16th March 2015/ 09.20

Chief Complain : Unconsciousness History : 30 minutes before admission the patients had a accident motor in the Gambut before admission. The patient hit by another motorcycle and fell to the aspalt. Helm (+) but take it out. Unconscious (+). Bleeding nose / mouth / ear ( - / + / - ). Nausea-vomitting (+/+). The patient taken to the Central hospital Martapura and then taken to the hospital Ulin Banjarmasin .

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Primary Survey

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General Status

A-M-P-L30 minutes before admissionEOn the road

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Laboratory Result March 4th 2015ItemsResultNormal ValueUnitHemoglobine11,914.00 - 18.00g/dlLeukocyte26,44.0 10.5thousand/ulEritrocyte3,624.00 5.50million/ulHematocrit33,932.00 44.00Vol%Trombocyte247150 450Ribu/ulRDW-CV13,511.5 14.7%MCV93,980.0 97.0FlMCH32,827.0 32.0PgMCHC35,132.0 38.0%

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ItemsResultNormal ValueUnitGran%86,050.0-70.0%Lymphocyte%8,325.0-40.0%MID%5,74.00-11.00million/ulGran#22,702.50-7.00Billion/ulLimfosit #2,21.25-4.0Billion/ulMID#1,5Billion/ul

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ItemsResultNormal ValueUnitPT11,59,9-13,5SecondAPTT24,522,2-37,0SecondSGOT960-46U/lSGPT810-45U/lBlood Urea2110-50mg/dLCreatinin0,80,7-1,4mg/dLNatrium 140,8135-146mmol/LKalium 3,93,4-5,4mmol/LChloride 104,295-100mmol/L

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Clinical Picture

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Local Statusa/r cruris sinistra :L: swelling (-), open wound (+) 8x6cmF: crepitation (+), pain (+)M: ROM limited due to pain (+)

X-ray

Working DiagnosisMild head injury GCS 14 (E3M6V5) + susp. Fraktur basis cranii + SAH + SDH a/r frontal dextra + open fracture of left + tibia distal 3rd obliq displaced + open fraktur of left calcacal + closed fracture of left fibula dextra

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Management

Obs vital signIVFD RL 20 tpmDCO2 6 Lpm maskerInj ceftriaxon 2x1 gInj Ranitidin 2x1 ampInj Ketorolac 2x30mgTranexamat acid 3x200mgX-ray cruris AP/LatX-Ray manus sin AP/lat

Co Sp.OT :ImobilisationPro ORIF

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Chief Complain : Open wound on the headHistory : 4 hours before admission patient complaint open wound on his head. Patient hone the stone, the grindstone was broken and struck his head. Open wound and bleeding (+), unconscious (-). Nausea-vomitting (-/-), pain on his head (+). The patient had a treatment in Marabahan hospital and then taken to the Ulin Banjarmasin Hospital.

Mr. Hardiman/ 49 y.o/ 1.14.36.84/ 15 March 2015/ 17.00 pm

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Primary Survey

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General Status

A-M-P-L-EOn the office

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Clinical Picture

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Status localis

a/r frontalis sinistraOpen wound 6x2x1 cm basic bone, broke (+), bleeding (+), side wound irreguler.

X-ray

CT-Scan

Working DiagnosisMild head injury GCS 15 + ICH a/r frontalis dextra 10cc + open fraktur os frontalis dextra

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Management

Co neuro surgery :Pro craniotomy

Obs vital signX-ray skull AP/latHead ct scan Wound toiletHectingIVFD RL 20 tpmKetorolac 3x30 mgRanitidin 2x1 ampCeftriaxon 2x1 grOndancentron 3x4 m

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Mrs. Nor Asiah/ 32 y.o/ 1.14.36.71 15th March 2015/10.55Chief Complain : pain on the right hand

History : 15 minutes before admission the patients had a accident with her sister. The patient hit by another motorcycle and fell to the street. Helm (+), Unconscious (-). Bleeding nose / mouth / ear ( - / - / - ). Nausea-vomitting (-/-). Patient have a swelling on the her right hand. Headache (+). The patient taken to the Ulin Banjarmasin Hospital.

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Primary Survey

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General Status

A-M-P-L-EOn the road

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Clinical Picture

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Localized Statusa/r manus: L: swelling (-), deformitas (-), open wound (-)F: pain (+), crepitation (-)M : ROM limitted (-)

X-ray

Working DiagnosisVulnus excoriation a/r manus

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Management

Trombopop gelMeloxicam 2x1

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Chief Complain : back painHistory : 30 minutes before admission patient hit by motorcycle and fell to the street. Unconscious (-). Bleeding nose / mouth / ear ( - / - / - ). Nausea-vomitting (-/-). The patient taken to the Ulin Banjarmasin Hospital.

Mr. Nasrudin/ 50 y.o/ 0.72.62.05/ 15 March 2015/ 14.30

66

Primary Survey

67

General Status


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Clinical Picture

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Status localized

a/r digiti manus IV sinistra : L: swelling (+), deformitas (-), open wound (+)F: pain (+), crepitation (-)M : ROM limitted (+)

Working DiagnosisVulnus laceratum et regio digiti manus IV sinistra

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Management

Wound toiletHectingATSCefodroxil 2x1Mefenamat acid 3x4

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Chief Complain : open wound on the left footHistory : 30 minutes before admission patients hit by motorcycle from the side and fell to the aspalt. Unconscious (-). Bleeding nose / mouth / ear ( - / - / - ). Nausea-vomitting (-/-), back pain (+). The patient taken to the Ulin Banjarmasin Hospital.

Miss. Sopia/ 13 y.o/ 1.14.36.72/ 15 March 2015/ 10.30 am

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Primary Survey

75

General Status


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Clinical Picture

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Status localized

a/r pedis dextra : L: swelling (+), deformitas (-), open wound (+)F: pain (+), crepitation (-)M : ROM limitted (+)

X-ray

Working DiagnosisVL a/r pedis dextra

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Management

Wound toiletPrimarry sutureATSMefenamat acid 3x1Ciprofloxacin 2x1Ranitidin 2x1

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Chief Complain : crowdedHistory : 2 weeks before admission patient complain crowded but in 2 days the crowded increase. 1 day before admission the patient has a hoarseness. The patient taken to the Pelaihari hospital and then taken to the Ulin Banjarmasin Hospital.

Mrs. Jumah/ 51 y.o/ 1.14.36.91/ 15 March 2015/ 23.30 pm

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Status generalisGCS 15 E4V5M6TD : 180/100RR 30x/mSpO2 : 98%

General Status

Clinical Picture

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Status localized

a/r coli dextra : bump (+) size 4x3 cm, mobile, lesion (-), tenderness (-)a/r laring via laringoschop : mass (+) bleeding (+)

X-ray

Working DiagnosisObs dispneu ec susp tumor laring

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Management

Obs vital signO2Inj. Ceftriaxon 2x1 gInj. Dexametason 3x1 ampInj. Ranitidin 2x1 amp

Co. onko :Pro tracheostomy

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Chief Complain : swelling on left eyeHistory : 6 hours before admission patients had a accident when driving a motorcycle with his friend. They driving with a mild speed. Helm (-), Unconscious (+). Bleeding nose / mouth / ear ( + / - / + ). Nausea-vomitting (+/+) on 3x, swelling on his left eye, wound on his right elbow. His history, he consume zenith + alcohol 1 hour before accident.

Mr. Nur Khalis/ 22 y.o/ 1.14.37.01/ 16 March 2015/ 03.10

92

Primary Survey

93

General Status

A-MZenith + alcohol (7 hours ago)P-L8 hours agoEOn the road

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Clinical Picture

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Status localized

a/r palpebra sinistra :L: swelling (+), deformitas (-), open wound (-)F: pain (+), crepitation (-)M : ROM limitted (+)

Status localizeda/r elbow dextra :L: swelling (-), deformitas (-), open wound (-)F: pain (+), crepitation (-)M : ROM limitted (+)

2015ItemsResultNormal ValueUnitHemoglobine14,714.00 - 18.00g/dlLeukocyte16,24.0 10.5thousand/ulEritrocyte4,474.00 5.50million/ulHematocrit41,232.00 44.00Vol%Trombocyte238150 450Ribu/ulRDW-CV13,811.5 14.7%MCV92,280.0 97.0FlMCH32,827.0 32.0PgMCHC35,632.0 38.0%

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ItemsResultNormal ValueUnitGran%87,250.0-70.0%Lymphocyte%7,425.0-40.0%MID%5,44.00-11.00million/ulGran#14,102.50-7.00Billion/ulLimfosit #1,21.25-4.0Billion/ulMID#0,9Billion/ul

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ItemsResultNormal ValueUnitPT11,49,9-13,5SecondINR1,00SGOT690-46U/lSGPT550-45U/lNatrium 135,9135-146mmol/LKalium 3,43,4-5,4mmol/LChloride 98,095-100mmol/L

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CT-Scan

CT-Scan

Working DiagnosisMild head injury GCS E4V5M6

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Management

O2Head up 30IVFD RLInj. Ketorolac 3x30 mgInj. Ranitidin 2x50 mgInj. Ceftriaxon 2x1 ampHead ct scanLab complete

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