Emergency Report

April 27
th
-28
th
, 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 List
No Identity Admission to
E.R.
Diagnosis Management
1. Child
Yasmin/ 7.5
months yo
April 27
th
,
2014 at
10.45
Total Ileus
obstruction e.c
Susp.invagination
BNO 3 position
USG abdominal
Laboratory Check and urinalize

IV Line
Antibiotic
Analgesic
H2 blocker
Fasting
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 alienum
Hecting
Analgetic
Antibiotic
H2 Blocker
Discharge 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
serial
Laboratorium check
Iv line
Catheterization (Fluid balance)
Hecting
Dressing
Analgesic
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
Hospitalize
Laboratorium check
Ct scan
catheterization
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 Status
Awareness: alert
GCS
15
: E
4
V
5
M
6


Vital sign
HR : 120 t/m
RR : 30 t/m
T : 37,
o
C
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 edem
Extremities
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
Management
BNO 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
simmetry
B
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 paralysis
D
-
A
-
M
-
P
6 hours before admission
L
On the river
E
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 status
Extremities
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: headache
History : 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
simmetry
B
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 paralysis
D
-
A
-
M
-
P
8 hours before admission
L
On the road
E
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 E3M6V5
Multiple 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 consciousness
History : 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
simmetry
B
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 paralysis
D
-
A
-
M
-
P
1 days before admission
L
On the road
E
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
Extremities
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