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Emergency Case Report

2014, 5 TH 6 TH December

Resident on Duty : dr. Alma Wijaya


Chief Co-Assistant : Ady
Team :
Endah, Erina, Mira, Firdha, Dyah, Bimo

Minor Surgery

:-

Digestive Surgery

Thorax Cardiovascular Surgery

Plastic Surgery

Urology Surgery

: 1 -

Neurosurgery

: 3

Pediatric Surgery

Oncology Surgery

:1

Orthopaedy

Total

:5

No

Identity

Ms. Annisa/
12y.o/
1.13.07.94

Admission
to E.R.

5th
December
2014/ 06.00
p.m

Diagnosis

Mild Head Injury GCS 15


+ Susp. Skull base
fracture anterior at medial
fossa + linier fracture at
right temporal region

Treatment / Planning

IVFD RL maintenance
Antibiotic
H2 blocker
Analgesic
Consulted to Neurology Surgery
Departement
Completely blood count
CT Scan Head

No

Identity

Mr. Kadiran/ 78
y.o/ 1.13.07.98

Admission
to E.R.

5th
December
2014/ 07.12
p.m

Diagnosis

Post Cytostomy d.t Susp.


Posterior Urethral
Stricture+ Benign Prostate
Hyperplasia + scrotal
absces

Treatment / Planning

IVFD RL:D5 maintenance


Antibiotic
Analgetic
H2 Blocker
Consulted to Urology Departement
USG Urology and scrotum
Planned to BVUC from wards

No

Identity

Mr. Ani Safitri/


18 y.o/
1.13.07.96

Admission
to E.R.

2014, 5TH
December/
06.30 p.m

Diagnosis

Treatment / Planning

Hipovolemic shock Rapid


Respon + severe head
injury GCS 7 E2M3V2 dd
Secondary Brain damage
+ Open Fraktur of left
humerus distal third +
open fracture of the left
femur midle third + open
fracture of left lateral
maleolus + closed fracture
of the right femur middle
third + obs blunt
abdominal trauma

Fluid Resusitation
Vital sign observation
Antibiotic
Analgesic
H2 blocker
Tetatus profilaksis
Co neurosurgeon :
Pro head CT if transportable
CO digestive surgeon :
Vital sign stabilisation
Pro Abdominal USG if transportable
Co orthopaedic surgeon :
Pro debridement and fixation when
Vital sign stable

No

4.

Identity

Mr.
Badriansyah/
68 y.o/
1.13.08.05

Admission
to E.R.

5th
December
2014/ 09.30
p.m

Diagnosis

Treatment / Planning

Intraventrikular
Haemorrhagic d.t Stroke
Haemorraghic

Consul Neurology Surgery Dept.


Pro EVD Cito
Antibiotik pre operation
H2 Blocker
Analgesic

No

Identity

Mrs. Rayati/ 48
y.o/ 1.13.08.16

Admission
to E.R.

6th
December
2014/ 01.15
a.m

Diagnosis

Left breast cancer T4dN3M1


lung + Anemia
With Karnofsky 50

Treatment / Planning

Consul Oncology dept


IVFD RL:D5 maintenance
Antibiotic
H2 Blocker
Analgesic
Dressing once in two days
Transf. PRC Hb 10
Pro Chemotherapy

1. Ms. Annisa/ 12y.o/ 1.13.07.94


5th December 2014/ 06.00 p.m
Chief Complain : Headache
History:
2 days ago before admission, the patient had an accident . The patient was hit by
a motorcycle at high speed. After the incident, patient was taken to ER Amuntai.
During treatment in there, patient experienced dizziness and vomiting of blood.
And both the patients eyes and behind the ears suffered bruising, the patient also
complaint persistent headache.
Because the complain patient in Amuntai Hospital, patient referred to Ulin General
Hospital for further treatment.

Primary Survey
A

Snoring (-), gurgling (-), bleeding


from the mouth
Clear, RR= 20 bpm, symmetric
respiratory movement, symmetric
VBS
BP : 110/80 mmHg
Pulse rate : 80 bpm, reguler, strong
lifted, CRT < 2 sec.
GCS E4V5M6, round and equal
pupils diameter (3mm/3mm), light
reflexes (+/+), no paralysis

1 hour before
admission

On the road

Physical Examination

Head/Neck

Chest

Abdomen

Extremities

Eyes : No anemic conjunctiva, icteric sclera (-), racon eye (+/+),


Batle sign (+/+)
Nose : No epistaxis
Mouth : Wet mucosa
Ear : behind the ear bruise (+/+)
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
I : Inguinal lymph nodes enlargment (-)
A : Bowel sound (+)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-), distension (-) at lower abdomen
P : Tymphani

Warm, no oedema, no parese, bruise (+)

Physical Examination

Head/Neck

Chest

Abdomen

Extremities

Eyes : No anemic conjunctiva, icteric sclera (-), bruise (+/+)


Nose : No epistaxis
Mouth : Wet mucosa
Ear : behind the ear bruise (+/+)
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

I : Symmetric respiratory movement, no retraction


P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
I : Inguinal lymph nodes enlargment (-)
A : Bowel sound (+)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-), distension (-) at lower abdomen
P : Tymphani

Warm, no oedema, no parese, bruise (+)

Clinical Picture Local Status

At Orbita
racon eye (+/+)

Clinical Picture Local Status

At Auricular

Batle sign (+/+)

CT SCAN HEAD
5TH Dec 2014

CT SCAN HEAD
5TH Dec 2014

CT SCAN HEAD
5TH Dec 2014

Laboratory

Hb 9.5 g/dl
Leukosit 10500/ul
Eritrosit 3300000/ul
Hct 27%
Trombosit 288000/ul
RDW-CV 14.1%
SGOT/PT 23/12 U/I
Ur/cr 14/0.5 mg/dL

Working Diagnosis
Mild Head Injury GCS 15 + Susp. Skull base fracture anterior at medial
fossa + linier fracture at right temporal region

Management
IVFD RL 1500cc/day
Antibiotic
H2 blocker
Analgesic
Consulted to Neurology Surgery Departement
Completely blood count
CT Scan Head

2. Mr. Kadiran/ 78 y.o/ 1.13.07.98


5th December 2014/ 07.12 p.m
Chief Complain : unable to void
History:

Since one week before hospital admission patient been complained


couldnt urinate. This is the first time patient experienced the complain.
The complaint also accompaied by scrotal oedema since 10 days ago
The patient then brought to tanah bumbu hospital and got open
cystostomy
The patient has history of urination since one year ago. Because his
complain patient referred to Ulin General Hospital for further treatment.

Physical Examination
Conciousness : Compos Mentis
Vital sign :
BP = 120/80 mmHg
PR = 80bpm
RR = 20 bpm
T = 36,8C

Physical Examination

Head/Neck

Chest

Abdomen

Extremities

Eyes : anemic conjunctiva, icteric sclera (-),


Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

I : Symmetric respiratory movement, no retraction


P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
I : Inguinal lymph nodes enlargment (-), cytostomy (+)
A : Bowel sound (+)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-),
P : Tymphani

Warm, no oedema, no parese

Clinical Picture Local Status

At scrotum region
L : swelling lump, oedem
(-), absess
F : Abscess (+) fluctuation
-

Clinical Picture Local Status


At scrotum region
L : swelling lump, oedem (-), absess

Abd AP

Laboratory

Hb 12.9 g/dl
Leucocyte 21000 /l
Hematocrit 38 vol%
Trombocyte 635000/ l
Glucose 133 mg/dl
SGOT/SGPT 32/37 U/l
Ur/cr 36/0.9 mg/dL

Working Diagnosis
Post Cytostomy d.t Susp. Posterior
Urethral Stricture+ Benign Prostate
Hyperplasia + scrotal absces

Management
IVFD RL:D5 maintenance
Antibiotic
Analgetic
H2 Blocker
Consulted to Urology Departement
USG Urology and scrotum
Planned to BVUC from wards

3. Mr. Ani Safitri/ 18 y.o/ 1.13.07.96


2014, 5TH December/06.30 p.m

Chief Complain: decrease of concious


History : 12 hours before admission, the patient want to go to
school and then was hit with a high-speed car. The patient was
found unconcious Then the patient was taken to the ER primary
health care in Sampit by the citizen the patient didnt got primary
survey adequately and then referred to to Ulin General

Hospital for further treatment.

Primary Survey
A

Clear, Snoring (-), gurgling (-),

Clear, RR= 22 bpm, symmetric


respiratory movement, symmetric
VBS

BP : not palpableres
90/60mmHg
Pulse rate : 80 bpm, reguler, strong
lifted, CRT >2 sec.

GCS E2V2M3, round and equal


pupils diameter (3mm/3m), light
reflexes (+/+), no paralysis

A Day before
admission
Road

Secondary survey
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

Head/Neck

Chest

I : Symmetric respiratory movement, retraction (-)


P : Symmetric VF
P : Sonor in all lung field
A : Symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen

I : Wound (-), distension (-), hematoma (-)


A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).
P : Tympanic in all quadrants

Extremities

Warm, edema (-), paralysis (-)


Wound (+)

Clinical Picture Local Status

At head region
L : Swelling (+), deformitas
(-), oedem (-), wound (+)
F : pain (-)

Laboratory

Hb 12.4 g/dl
Leucocyte 37900/l
Hematocrit 36.3 vol%
Trombocyte 385000/ l
SGOT/SGPT 207/116U/l
Ur/Cr 41/2.8 mg/dL
Na/K/Cl 139/5/102 mmol/l

Working Diagnosis
Hipovolemic shock Rapid Respon + severe head injury GCS 7
E2M3V2 dd Secondary Brain damage + Open Fraktur of left
humerus distal third + closed fracture of the left femur midle
third + open fracture of left lateral maleolus + closed fracture
of the right femur middle third + obs blunt abdominal trauma

Management
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4. Mr. Badriansyah/ 68 y.o/ 1.13.08.05


5th December 2014/ 09.30 p.m
Chief Complain : Headache
History:

since 4 days ago the patient complain about


headache, nausea, and vomiting. Vomiting 4 times and
contains the food eaten. The patient felt the headache did
not relief by analgesia and. History of fainting seizure -.
The patient has history of uncontrolled hipertention since
couple
years
ago.

Physical Examination
Conciousness : Compos Mentis
Vital sign :
BP = 160/100 mmHg
PR = 90 bpm
RR = 20 bpm
T = 36,5C

Physical Examination

Head/Neck

Chest

Abdomen

Extremities

Eyes : anemic conjunctiva, icteric sclera (-),


Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

I : Symmetric respiratory movement, no retraction


P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
I : Inguinal lymph nodes enlargment (-)
A : Bowel sound (+)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-),
P : Tymphani

Warm, no oedema, no parese

Clinical Picture Local Status

CT Scan Head

CT Scan Head

Laboratory

Hb 13.2 g/dl
Leucocyte 13600 /l
Hematocrit 36.5 vol%
Trombocyte 269000/ l
Glucose 114 mg/dl
Cholest. 177 mg/dl
TGT 60 mg/dl

Working Diagnosis
Intraventrikular Haemorrhagic d.t Stroke Haemorraghic

Management
ConsuN
l euroolgySurgeryDept.
ProEVDCtoi
Anbtioiktipreoperaotin
H2Bol cker
Anagl esci

5. Mrs. Rayati/ 48 y.o/ 1.13.08.16


6th December 2014/ 01.15 a.m
Chief Complain : lumb in the breast
History: since one year before admission the patient

complained of a lump in the left breast. The lump is getting


bigger day by day, the patient has a history of FNAB but the
patient refuse chemotherapy. Now the lump are
accompanied with bleeding ulcer. And the patient complaint
shortness
of
breath.

Physical Examination
Conciousness : Compos Mentis
Vital sign :
BP = 110/80 mmHg
PR = 92 bpm
RR = 24 bpm
T = 36,5C

Physical Examination

Head/Neck

Eyes : anemic conjunctiva, icteric sclera (-),


Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Chest

I : Symmetric respiratory movement, no retraction. Lump (+) left


breast.
P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing

Abdomen

I : Inguinal lymph nodes enlargment (-)


A : Bowel sound (+)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-),
P : Tymphani

Extremities

Warm, no oedema, no parese

Clinical Picture Local Status

Laboratory

Hb 7.6 g/dl
Leucocyte 13400 /l
Hematocrit 24.9 vol%
Trombocyte 576000/l
Eritrocyte 2720000/ul

Working Diagnosis
Left breast cancer T4dN3M1 lung metastase + Anemia
With Karnofsky 50

Management
ConsuO
l ncoolgydept
IVFDRL:D5manitenance
Anbtioicti
H2Bolcker
Anaglesci
Dressnigoncenitwodays
Transf.PRCHb10
ProChemohterapy