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8/12/2019 LapJag 8 Dan 9 Feb 2014
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Emergency
Report
February 8
th
-
9
th
,
20
14
Chief on duty: Okta
Resident on duty:Dr. Alexander
Team:
Rajihah, Dila, Bayu, Farid, Joyce, Yasmin, Desy
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Minor surgery : -
Oncology surgery : -
Digestive surgery : 3
Thorax cardiovascular surgery : -
Plastic surgery : 1
Urology surgery : -
Neurosurgery :
Pediatric surgery : -
Orthopedic : 2
Total : 6
PATIENT LIST
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Patients ListNo Identity Admission to
E.R.
Diagnosis Management
1. Girl Silma
Lathifah/15y.o
February
8nd
, 2014 at 14.35
Constipation d.t
scibala with
hemorrhoid Gr.I
Laxative
Analgetic
H2 Blocker
Hemorrhoid drug
Discharge by permission
2 Boy Alex/
14 yo
February
8nd, 2014
at 18.00
Soft tissue
Swelling at right
cubiti
Analgetic IV
Rontgent Thorax and Cubiti
Co. Orthopedic
Oral Analgetic
Discharge by permission
3 Child Ida
Ariani/ 16yo
February
8nd
, 2014 at 18.00
Closed Fracture at
left ulna distal
third transvere
displace + close
fracture at left
tibial spine Meyer
Mc.Kiever II +
multiple
excoriation
IV Line
Analgetic
Antibiotic
H2 Blocker
Rontgen Thorac, pelvic , femur and
knee
Co. Orthopedic:
Posterior SlabORIF
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No Identity Admission to
E.R.
Diagnosis Management
4 Mrs.
Herawati/
31 yo
February
8th 2014,
at 18.20
Susp.Acute
AppendicitisIV Line
H2 blocker
Laboratory check
Co. Digestive
Appendectomy emergency
5 Baby Nilna
Muna/ 10months
February
8th
2014,at 19.10
Burn Injury at right
wrist, left tight, left
leg and left foot
Gr.IIA 3,5%
IV Line
AnalgeticWound toilet
6 Mr.
Fahruzzaini/
54 yo
February
9th 2014
at 06.30
Diffuse
peritonitis d.t
susp. Gastricperforation +
CKD gr. V
IV Line
Antibiotic
Analgetic
Laboratory check
Co. Digestive
Diuretic
Emergency Hemodialysis
Hospitalized in ICU posthemodialysis
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1. Girl Salma Lathifah/ 15 yo/ February 8th
2014 at 14.35
Chief complain: abdominal pain
History :
± last 2 days, patient complaint abdominal pain at whole
abdomen. The pain was intermitent. Patient also complaintconstipation. The stool was hard and often with blood at theend of defecation. Lump from anus (-)
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General Status
Awareness: alert
GCS15 : E4V5M6
Vital sign
• BP : 100/70 mmHg
• HR : 72 t/m
•
RR : 20 t/m• T : 36,7 oC
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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 (-)
•A : normal Bowel sound
•P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,
rebound tenderness (-)•P : Tympani
Abdomen
•Warm,, no parese, no edemExtremities
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Physical Examination• Local status :
Flat, supple, tenderness(-),
Rebound tenderness (-),
normal bowel sound
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Laboratory Findings
• Hemoglobin : 11,1
• WBC : 7,5
•
RBC : 4,58• Hematocrit: 35,1
• PLT: 375
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Laboratory Findings
Urinalize
• Color Cloudy Yellow
• BJ : 1.010
• pH: 6,5
• Keton: -
• Occult Blood: -
• Urobilinogen: 0,2
Sediment
•Leucosit 3-5
•Erytrosit 0-1
•Selinder -
•Epithel +1
•Bactery -
•Crystal -
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Clinical Picture
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Working Diagnosis
Constipation d.t scibala with hemorrhoid gr. I
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Management
Laxative
Analgetic
H2 BlockerHemorrhoid drug
Discharge by permission
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2. Child Alex/ 15 yo/ February 8th 2014 at
18.00
Chief complain: Right elbow painHistory :
± 15 minutes before admission, patient was riding amotorcycle. Helmet (-). And then crushed by other motorcyclefrom right back. Unconsiousness (-), vomit (-), nose/ear/mouthbleeding (-/-/-), seizure (-). His chin and chest was hit the roadand his right elbow folded.
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Primary Survey
• Clear, gurgling (-), snoring (-)A
• Clear, RR=20 bpm, symmetricrespiratory movement, symmetric
VBSB
• BP : 120/70 mmHg• Pulse rate : 90 bpm, reguler, strong
lifted, CRT < 2 sec.
C
•GCS E4V5M6, round and symmetricpupils diameter (3mm/3m), light
reflexes (+/+), no paralysisD
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A -
M -
P -
L 4 hours before
admission
E On the road
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Secondary Survey
•Eye : Anemic conjunctivae (-/-), icteric sclera (-/-)
•Mouth : Wet mucose
•Neck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
• I : Symmetric respiratory movement, lesion (-)
• P : Symmetric VF
• P : Sonor in all lung field
• A : symmetric VBS, Rh (-/-), Wh (-/-)Chest
• I : lesion (-), distension (-)
• A : Normal bowel sound
• P : H/L/M not palpable, tenderness (-), mass (-)
• P : Tympanic in all quadrantsAbdomen
• Warm peripher (+), edema (-) parese ( - / - ), other see statuslocalis, swelling (-) Extremities
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Local Status
Cubiti Dextra
• L: Hematome (+), Swelling
(+), deformitas (-)
• F: Tenderness (-),
crepitation (-), distal
sensibility (+)
• M: ROM limited due to
pain
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Chest X-Ray
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Right Hand X-Ray
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Working Diagnose
• Soft Tissue Swelling at right cubiti
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Management
• Analgetic IV
• Rontgent Thorax and Right Cubiti
• Co. Orthopedic
• Oral analgetic
• Discharge by permission
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3. Child Ida Ariani/ 16 yo/ February 8th 2014 at
18.00
Chief complain: Pain at left arm and left kneeHistory :
± 15 minutes before admission, patient was riding amotorcycle. Helmet (-). And then crushed by other motorcycle.Unconsiousness (-), vomit/nausea (-/-), nose/ear/mouthbleeding (-/-/-), seizure (-). Patient complaint pain at left armand left knee.
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Primary Survey
• Clear, gurgling (-), snoring (-)A
• Clear, RR=20 bpm, symmetricrespiratory movement, symmetric
VBSB
• BP : 120/80 mmHg• Pulse rate : 80 bpm, reguler, strong
lifted, CRT < 2 sec.
C
•GCS E4V5M6, round and symmetricpupils diameter (3mm/3m), light
reflexes (+/+), no paralysisD
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A -
M -
P -
L -
E On the road
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Secondary Survey
•
Eye : Anemic conjunctivae (-/-), icteric sclera (-/-) other seestatus localis
•Mouth : Wet mucose
•Neck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
• I : Symmetric respiratory movement, lesion (-)
• P : Symmetric VF• P : Sonor in all lung field
• A : symmetric VBS, Rh (-/-), Wh (-/-)
Chest
• I : lesion (-), distension (-)
•
A : Normal bowel sound• P : H/L/M not palpable, tenderness (-), mass (-)
• P : Tympanic in all quadrantsAbdomen
• Warm peripher (+), edema (-) parese ( - / - ),other see statuslocalis Extremities
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Clinical Picture
L l S
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Local Status
Left wrist Region
L: swelling (+), deformitas
(+)
F: pain (+), crepitation (+)
M: ROM limited due topain
L l S
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Local Status
Mentalis RegionL: Vulnus laceratum (+)
size 1x1 cm, bleeding (-)
F: pain (+), crepitation (-)
L l S
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Local Status
Knee RegionL: Swelling(+)
hematome(-)
F: tenderness (+),crepitation (-)
M: ROM Limited
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Chest X-Ray
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Left Forearm X-Ray
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Pelvic X-Ray
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Left Femur X-Ray
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X-Ray
Left Knee JointLeft Ankle Joint
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Working Diagnose
Closed Fracture at left ulna distal third transvere
displace + close fracture at left tibial spine
Meyer Mc.Kiever II + multiple excoriation
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4. Mrs. Herawati/ 31 yo/ February 8th 2014 at
18.20
Chief complain: Pain at right lower abdomenHistory :
Since 1 days before admission, the patient felt pain at her right
lower abdomen continuously and more intense. Initially the
pain was felt at the epigastric region, and then it moved and
remained at the right lower abdomen. History of nausea (+),vomiting (+), constipation since 4 days ago. Urinating within
normal limit.
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General Status
Awareness: alert
GCS15 : E4V5M6
Vital sign
• BP : 100/70 mmHg
• HR : 76 t/m
•
RR : 18 t/m• T : 37,3 oC
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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 field
•A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)Chest
• I : flat, distention (-)
•A : normal Bowel sound
•P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (+) ,
rebound tenderness (+)•P : Tympani
Abdomen
•Warm,, no parese, no edemExtremities
Physical Examination
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Physical Examination
• Local status :
–
At abdominal region :supple, distension (-),
bowel sound normal,
tenderness(+) at mc
burney point, rebound
tenderness (+), timpany
– ALVARADO score : 8
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Digital Rectal Examination
Look
•
Mass (-)• Abration (-)
• Hemoroid (-)
• Oedem (-)
• Eritema (-)
Feel
•
Normal analsphinctertone
• Smooth
mucosa• Tenderness
in 9 hour
Handschoon
•
Feces (+)• Mucus (-)
• Blood (-)
Clinical Picture
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Clinical Picture
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Laboratory Findings
• Haemoglobin: 11,6• WBC: 14,7
• RBC: 4,00
•
Hematocrit: 34,6• PLT: 349
• SGOT/SGPT: 22/19
•
Ur/Cr: 32/1,1
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Working Diagnose
Susp.Acute Appendicitis
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5. Baby Nilna Muna/ 10 months/ February 8th
2014 at 19.10
Chief complain: Wound at left tight and legHistory :
± 30 minutes before admission, patient was spilled by hot
water at left tight and left leg. History of trauma (-)
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General Status
Awareness: alert
GCS15 : E4V5M6
Vital sign
• HR : 140 t/m
• RR : 32 t/m
•
T : 36,7
o
C
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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 field
•A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)Chest
• I : flat, distention (-)
•A : normal Bowel sound
•P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,rebound tenderness (+)
•P : Tympani
Abdomen
•Warm,, no parese, no edemExtremities
Physical Examination
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Physical Examination
• Local status :
– At right wrist region :Burn injury gr. IIA
0,5%
Physical Examination
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Physical Examination
• Left Tight : burn injury
Gr. IIA 1,5 %• Left leg : burn injury
Gr. IIA 0,5%
• Dorsum foot : burn
injury Gr.IIA 1%
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Working Diagnose
Burn Injury at right wrist, left tight, left leg and
left foot Gr.IIA 3,5%
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h i i/ / b 9 h 20
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6. Mr. Fahruzzaini/ 54 yo/ February 9th 2014 at
06.30
Chief complain: abdominal painHistory :
since ±2 days before admission, patient complaint cant do
micturition. Patient also complaint abdominal pain and difficult
to defecation. Difficult to urinate, decrease stream (-), Bloody
urinate (-), sandy urinate (-), stone urinate (-). History ofconsumption pain relievers for 1 year. Trauma (-).
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General Status
Awareness: alert
GCS15 : E4V5M6
Vital sign
• BP : 90/60 mmHg
• HR : 140 t/m
• RR : 32 t/m
• T : 36,7 oC
h i l i i
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Physical Examination•Toxic face
•
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 field
•A : symmetric VBS+/+, rhonchi (+/-), wheezing (-/-)Chest
• I : convex, distention (+)
•A : decrease Bowel sound
•P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (+) ,rebound tenderness (+)
•P : Tympani
Abdomen
•Warm,, no parese, no edemExtremities
Physical Examination
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Physical Examination
• Local status :
Convex, distention (+),tenderness(+), Rebound
tenderness (+),
decrease bowel sound
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Clinical Picture
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DRE
Look
• Mass (-)
• Abration (-)
• Hemoroid(-)
• Oedem (-)• Eritema (-)
Feel
• Weak anal
sphinctertone
• Smooth
mucosa
Handschoon
• Feces (+)
• Mucus (-)
• Blood (-)
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Laboratory Findings
•Haemoglobin: 12,1
• WBC: 7,0
• RBC: 4,11
•
Hematocrit: 34,9• PLT: 479
• SGOT/SGPT: 55/24
• Cr: 5,8
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Abdomen X-Ray
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Working Diagnose
Diffuse peritonitis d.t susp. Gastric perforation +
CKD gr. V
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Management
IV Line
Antibiotic
Analgetic
Laboratory check
Co. Digestive
DiureticEmergency Hemodialysis
Hospitalized in ICU post hemodialysis