Emergency Report

okt 20-21th 2015

Resident on duty:
dr. deni budinata
dr. Yan aditya
Chief: Bernadeth
Sally, nia , laila, panji,
rifqy, panji,

General Surgery

Digestive Surgery

Thorax Cardiovascular Surgery :

Plastic Surgery

Urology Surgery

Neuro Surgery

Pediatric Surgery

Total

:
:

Oncology Surgery
Orthopaedy

Patient List
No
1.

Identity

Admission to
ER

Mrs. Alsyaturidma / Oct 5 th ,

43 y.o/ 1186508
2015

Diagnose
Left breast Tumor
suspected maligna
T4CN1M1 (contralateral)
+ hiponatremi
Karnofski 60

Treatment

VS obs
02
IVFD NS
Analgetic
H2 blocker
Complete blood
count
Consulted to
oncology
surgery:
Hospitalized
Coagulant
Breast USG
FNAB +biopsi

Patient List
No
2.

Identity
Mr. husairin / 44
y.o/ 1186914

Admission to
ER
Oct 5 th ,
2015

Diagnose
Dysphagia due to susp
laryng tumor Karnofski
60

Treatment

VS obs
IVFD NS
Analgetic
H2 blocker
Complete blood
count
Thorax x ray
Consulted to
oncology
surgery:
Hospitalized
ATB
Consult ENT from
ward

1. Mrs. Alsyaturidma / 43 y.o/ 1186508

Chief Complain:
Mass at right breast
History of Current Disease:
Since one year before admission, patient complain
mass at her right breast when it first known the
mass as big as marble, she didnt feel pain at her
breast and the mass getting bigger until as big as
apple now , the mass broke up two days ago with
bleeding and pus. No history of fever, no history of
trauma at her breast patient get menarche at 12 yo.
And menstruation cycle was normal. and patient still
get menstruation, History of breast feeding (+), she
was delivered her first child at 20 yo. No familial
history of cancer, history of hormonal contraception
(+). Because of her complain patient was brought by
her family to oncologist surgeon and referred to

Physical Examination
Conciousness : compos mentis
Vital sign :
BP = 100/70 mmHg
PR = 90 bpm
RR = 24 bpm
T = 36,7C

General Status
Head/Nec
k

Chest

Abdomen

Extremitie
s

Eyes : anemic conjunctiva, (+) icteric sclera (-)

Mouth : Wet mucous
Neck : Lymph nodes enlargement (-), JVP enhancement (-).

I : Symmetric respiratory movement,no retraction, malignancy

ulcers (+)
P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-), no wheezing

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

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

Warm extremities, parese (-), edema (-)

Clinical Picture
Breast tumor 15
cm diameter, peu d
orange (+),
malignancy ulcer
(+)
hard consistency,
fixed to chest wall

Laboratory (06-02-2015)
Examination

Result

Normal value

hemoglobin

10.2

11.00-16.00

g/dl

Leucosit

8.1

4.0-10.5

Ribu/ul

eritrosit

3.51

4.50-6.00

juta/ul

hematocrit

31.3

42.00-52.00

Vol%

trombocit

359

150-450

Ribu/ul

Random Blood
Glucose

159

<200

Mg/dL

SGOT

91

0-46

U/I

SGPT

35

0-45

U/I

Urea

38

10-50

Mg/dL

Creatinine

1.2

0.7-1.4

Mg/dL

Na

128.7

135-146

Mmol/l

3.6

3.4-5.4

Mmol/l

Cl

98.8

95-100

Mmol/l

Thorax x ray

Working Diagnosis
Left breast Tumor suspected maligna T4CN1M1
(contra lateral) + hiponatremi Karnofski 60

Management
VS obs
02
IVFD NS
Analgetic
H2 blocker
Complete blood count
Consulted to oncology surgery:
Hospitalized
Coagulant
Breast USG
FNAB +biopsi

2. Mr. husairin / 44 y.o/ 1186914

Chief Complain:
Dysphagia
History of Current Disease:
Since one year before admission, patient complain
dysphagia and unable to speak , before unable to
speak patient complain hoarness.no history of
bloody sputum Since last week patient cant swallow
any food. No history of fever, no history of trauma
History of smoking (+) for 20 years. No familial
history of cancer. patient loss his body weight in last
six month.no history of biopsy before, no history of
laryngoscopy before.
Because of his complain
patient was brought by her family to Kotabaru
hospital and referred to ULIN general hospital to get
further treatment patient need to be help in mostly
of his daily activities.

Physical Examination
Conciousness : compos mentis
Vital sign :
BP = 110/70 mmHg
PR = 80 bpm
RR = 28 tpm
T = 36,7C

General Status
Head/Nec
k

Chest

Abdomen

Extremitie
s

Eyes : anemic conjunctiva, (-) icteric sclera (-)

Mouth : Wet mucous
Neck : Lymph nodes enlargement (-), JVP enhancement (-).

I : Symmetric respiratory movement,no retraction,

P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-), no wheezing

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

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

Warm extremities, parese (-), edema (-)

Clinical Picture

Laboratory (06-02-2015)
Examination

Result

Normal value

hemoglobin

11,8

11.00-16.00

g/dl

Leucosit

16,8

4.0-10.5

Ribu/ul

eritrosit

4,38

4.50-6.00

juta/ul

hematocrit

31.3

42.00-52.00

Vol%

trombocit

359

150-450

Ribu/ul

Random Blood
Glucose

153

<200

Mg/dL

SGOT

32

0-46

U/I

SGPT

35

0-45

U/I

Urea

38

10-50

Mg/dL

Creatinine

1.2

0.7-1.4

Mg/dL

Na

125.7

135-146

Mmol/l

3.5

3.4-5.4

Mmol/l

Cl

95.1

95-100

Mmol/l

Thorax x ray

Working Diagnosis
Dysphagia due to susp laryng tumor Karnofski 60

Management
VS obs
IVFD NS
Analgetic
H2 blocker
Complete blood count
Thorax x ray
Consulted to oncology surgery:
Hospitalized
ATB
Consult ENT from ward