Emergency Case Report

TEMPLATE

Resident on Duty : dr. Jacky Junaedi

dr. Immanuel Hendro
Chief Co-Assistant :
Inas

Team :
Dwiputra, Annandra, Dita, Hafidz, Hidayati,
Puja
Minor Surgery :-

Digestive Surgery :1

Thorax Cardiovascular Surgery : -

Plastic Surgery :-

Urology Surgery :1

Neurosurgery :1

Pediatric Surgery :1

Oncology Surgery :-

Orthopaedy :-

Total :3
 Patient List
No Identity Admission Diagnosis Treatment
to E.R.
1. Mrs. Anni April 24th Post VP Shunt a/i HC ec IVH + VS Obs
Suspek ventriculitis + IVFD NS
Danelson/ 2015 at
Hiponatremi + pressure sore OPA
19.00
67yo/1-14 - WITA
Inj Antibiotic
64-13 Inj analgesic
Rawat luka
Enteral Diet via NGT
Pro lumbal punction

Consult to
Neurosurgeon
Hiponatremia
Correction
Hospitalized

A L R CT ECG
 Patient List
No Identity Admission Diagnosis Treatment
to E.R.
2. Mr. Gusti April 24th Obstructive Jaundice VS Obs
observation ec Susp CBD Cyst + IVFD Asering
Noor / 2015 at
Choleliihiasis + Moderate rehydrating
20.10
46yo/0-96 - Cholangitis + Hyponatremia Inj. Antibiotic
WITA Inj. Analgesic
79-57
Inj. H2Blocker

Complete blood
count
Thorax X ray

Consult to Digestive
surgeon:
Antibiotic
Abdominal CT SCAN
AFP & Gamma GT
Test
Rehydration and
hyponatremia
correction
Hospitalized
A L R CT ECG
 Patient List
No Identity Admission to Diagnosis Treatment
E.R.
3. Mr. Mahyuni April 24th Post sectio alta due Urine VS Obs
retention due to Prostate IVFD RL
41yo/1-14 -86- 2015 at
hyperplasia + HIL dextra Inj antibiotic
20.30 WITA reponible Inj analgesic
65
Inj H2Blocker

Complete blood count

Consult to Urology surgeon:

USG Urology
PSA
Consult to Digestive
department
Hospitalized

Consult to digestive surgeon:

Treat the HIL first
Planing herniotomy +
hernioraphy

A L R CT ECG
1. Mrs. Anni Danelson/ 67yo/1-14 -64-13
April 24th 2015 at 19.00 WITA
Chief Complain :
Decreasing level of consciousness
History :
36 days before admission patient experienced decreasing
level of consciousness when she was sleeping. According to her
family, she was unable to be awaken. Her family rushed her to
Kapuas Hospital. The examination results showed hemorrhagic
stroke and intracranial hemorrhagic.
She later got referred to Suaka Insan hospital and
underwent (EVD) surgery there. According to her family, she was
hospitalised in ICU for 28 days, before she got permanent
drainage. Afterwards, the patient consciousness level was getting
better. She had more responses to external stimulus and got
transferred to the regular hospital wing before got dismissed by
permission.

L R CT ECG
 The patient has been staying at home for 4 days,
but her condition was getting worse. She has began to
be less responsive and eventually no more conscious.
The patient often got fever too. Her family rushed her
to Dorrys Sylvanus Hospital and got hospitalised there
for 4 days.
The patient has begun to develop open wound on
her coccyges area due to prolong bedridden. Due to
her conditions, the patient got referred to Ulin
Hospital for further treatment.
Vital Sign
BP : 140/90 mmHg
PR : 90 bpm
RR : 20 tpm
T : 37,1oC

A L R CT ECG
 Head : normocephali

General
Head/Neck Status
Eyes : anemic conjunctiva, (-/-) icteric sclera (-/-), edema palpebra
(-/-)
Mouth : Wet mucous
Neck : Lymph nodes enlargement (-/-), JVP enhancement (-/-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
Chest P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-/-), wheezing (-/-)

I : distension (-), convex (+)

A : Bowel sound (+) normal
Abdomen P : Liver/spleen/kidney not palpable, mass not palpable Tenderness
(-). Rebound pain (-) Muscular Defense (-)
P : Tymphani

Warm extremities, edema (-), motoric (difficult to evaluate)

Extremities Sensory (difficult to evaluate)

A L R CT ECG
Neurological Status
GCS E2V2M3 (7), Round and
symmetric pupils diameter
(2mm/2mm), Light reflexes (+/+),
parese (-/-/-/-), lateralization (-)

A L R CT ECG
Clinical Pictures

A L R CT ECG
Local Status

A L R CT ECG
Laboratory Result April 24th 2015
Items Result Normal Value Unit

Hemoglobine 10,81 14.00 - 18.00 g/dl

Leukocyte 16,6 4.0 10.5 thousand/ul

Eritrocyte 4,00 4.00 5.50 million/ul

Hematocrit 35,3 32.00 44.00 Vol%

Thrombocyte 581 150 450 Ribu/ul

RDW-CV 16,3 11.5 14.7 %

MCV 88,3 80.0 97.0 Fl

MCH 27,0 27.0 32.0 Pg

MCHC 30,5 32.0 38.0 %

A R CT ECG
 Items Result Normal Value Unit

Gran% 85,2 50.0-70.0 %

Lymphosite% 8,3 25.0-40.0 %

MID% 6,5 4.00-11.00 million/ul

Gran# 14,10 2.50-7.00 Billion/ul

Limfosit # 1,4 1.25-4.0 Billion/ul

MID# 1,1 Billion/ul

A R CT ECG
 Items Result Normal Value Unit
GDS 337 <200 Mg/dL

PT 11,1 9,9-13,5 Second

APTT 25,4 22,2-37,0 Second

INR 0,97

SGOT 54 0-46 U/l

SGPT 51 0-45 U/l

Albumin 3,8 3,5-5,5 g/dL

Ureum 29 10-50 mg/dL

Creatinin 0,6 0,7-1,4 mg/dL

Natrium 120,1 135-146 mmol/L

Kalium 4,0 3,4-5,4 mmol/L

Chloride 79,2 95-100 mmol/L

A R CT ECG
Thorax X-Ray April 22nd 2015 at Suaka
Insan Hospital

A L CT ECG
Head CT-SCAN April 24th 2015

A L R ECG
Working Diagnosis
Post VP Shunt a/i HC ec IVH + S. ventriculitis +
Hyponatremi

A L R CT ECG
Management
VS Obs
IVFD NS
Inj Antibiotic
Inj analgesic
Inj H2Blocker

Enteral Diet via NGT

Complete blood count

Consult to Neurosurgeon
Pro lumbal punction
Hyponatremi Correction
Hospitalised
A L R CT ECG
2. Mr. Gusti Noor / 46yo/0-96 -79-57
April 24th 2015 at 20.10 WITA
Chief Complain :
yellowish body
History :
Patient has been complaining that his body turned yellowish
since 2 weeks before admission. His complain getting worse
each day, even though he has never experienced it before. The
patient has been passing pale stool on recent days. The patient
also has been complaining upper right quadrant abdominal pain
since last 2 weeks. Its getting worse with intermittent fever. The
patient has no history of alcohol consumption. Due to his
complaints, the patient went to Tanah Bumbu hospital for
medical help before got referred to Ulin Hospital for further
examination. History of DM nor HT denied.

L R CT ECG
Vital Sign
BP : 100/60 mmHg
PR : 108 bpm
RR : 22 tpm
T : 36,8oC
SpO2: 98%

A L R CT ECG
 Head : normocephali

General
Head/Neck Status
Eyes : anemic conjunctiva, (-/-) icteric sclera (+/+), edema palpebra
(-/-)
Mouth : Wet mucous
Neck : Lymph nodes enlargement (-/-), JVP enhancement (-/-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
Chest P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-/-), wheezing (-/-)

I : distension (-), convex (+)

A : Bowel sound (+) normal
P : Liver/spleen/kidney not palpable, mass not palpable,
Abdomen Tenderness (+) a/r right upper quadrant. Rebound pain (-)
Muscular Defense (-)
P : Tymphani

5 3 + +
Extremities Warm extremities, edema (-), motoric Sensory
5 3 + +

A L R CT ECG
Rectal Touche
Anal sphincter tone (strong)
Mucous membrane sleek and smooth
Ampulla recti was not collapsed
Mass was not palpable
Tenderness (-)
BCR (+)
Faeces (+) yellow, Blood (-)
Clinical Pictures

A L R CT ECG
Local Status

a/r abdomen
I : distension (-), convex (+)
A : Bowel sound (+) normal
P : Liver/spleen/kidney not palpable,
mass not palpable, Tenderness (+) a/r
right upper quadrant. Rebound pain (-)
Muscular Defense (-)
P : Tymphani

A L R CT ECG
Laboratory Result April 24th 2015
Items Result Normal Value Unit

Hemoglobine 13,0 14.00 - 18.00 g/dl

Leukocyte 23,7 4.0 10.5 thousand/ul

Eritrocyte 4,37 4.00 5.50 million/ul

Hematocrit 38,8 32.00 44.00 Vol%

Thrombocyte 130 150 450 Ribu/ul

RDW-CV 19,4 11.5 14.7 %

MCV 89,4 80.0 97.0 Fl

MCH 29,70 27.0 32.0 Pg

MCHC 33,5 32.0 38.0 %

A R CT ECG
 Items Result Normal Value Unit

Gran% 81,5 50.0-70.0 %

Lymphosite% 7,1 25.0-40.0 %

MID% 11,4 4.00-11.00 million/ul

Gran# 19,30 2.50-7.00 Billion/ul

Limfosit # 1,7 1.25-4.0 Billion/ul

MID# 2,7 Billion/ul

HBs Ag (Cobas) Negative < 0,9 = non reactive

A R CT ECG
 Items Result Normal Value Unit
GDS 90 <200 Mg/dL

Bilirubin Direct 13,52 0,2-1,2 Mg/dL

Bilirubin Indirect 9,64 0,00-0,40 Mg/dL

Bilirubin Total 23,16 0,2-0,6 Mg/dL

SGOT 100 0-46 U/l

SGPT 57 0-45 U/l

Protein total 6,0 6,2-8,0 mg/dL

Albumin 2,8 3,5-5,5 g/dL

Ureum 197 10-50 mg/dL

Creatinin 1,9 0,7-1,4 mg/dL

Natrium 121,7 135-146 mmol/L

Kalium 1,4 3,4-5,4 mmol/L

Chloride 76,6 95-100 mmol/L

A R CT ECG
Thorax X-Ray April 22th 2015 at Tanah
bumbu Hospital

A L CT ECG
USG April
22nd
2015 at Tanah
Bumbu Hospital

A L R ECG
Working Diagnosis
Obstructive Jaundice observation ec Susp
CBD Cyst + Choleliihiasis + Moderate
Cholangitis + Hyponatremia

A L R CT ECG
Management
VS Obs
IVFD Asering rehydrating
Inj. Antibiotic
Inj. Analgesic
Inj. H2Blocker
Complete blood count
Thorax X ray
Consult to Digestive surgeon:
Antibiotic
Abdominal CT SCAN
AFP & Gamma GT Test
Rehydration and hyponatremia correction
Hospitalized
A L R CT ECG
3. Mr. Mahyuni 41yo/1-14 -86-65
April 24th 2015 at 20.30 WITA
Chief Complain :
Post Operation
History :
1x24 hours before admission, the patient was underwent surgery due
to his prostate enlargement which caused him unable to miction. They
were planned to put permanent cable to him, but according to his
family and the nurses, the surgery was unsuccessful due to adhesion.
The patient got referred shortly afterwards.
The patient has history of unsatisfying miction since a year ago. It was
frequent and usually painful. The patient often awoken at night to
urinate. He also have to push to put it out. 1 day before admission, the
patient was unable to urinate at all. He got catheter installment at
Buntok Hospital before got referred to Ulin Hospital. Patient has
history lump on right groin for last 5 years. The lump came out when
the patient stand and release if patient lay down. There no history of
bloody stool, no history of abdominal distention, there no history of
nausea and vomitus.

L R CT ECG
Vital Sign
BP : 120/80 mmHg
PR : 90 bpm
RR : 20 tpm
T : 36,7oC

A L R CT ECG
 Head : normocephali

General
Head/Neck Status
Eyes : anemic conjunctiva, (-/-) icteric sclera (-/-), edema palpebra
(-/-)
Mouth : Wet mucous
Neck : Lymph nodes enlargement (-/-), JVP enhancement (-/-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
Chest P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-/-), wheezing (-/-)

I : distension (-), convex (+)

A : Bowel sound (+) normal
Abdomen P : Liver/spleen/kidney not palpable, mass not palpable Tenderness
(-). Rebound pain (-) Muscular Defense (-)
P : Tymphani

5 5 + +
Extremities Warm extremities, edema (-), motoric Sensory
5 5 + +

A L R CT ECG
CVA

Ins : bruise (-/-), hematoma (-/-)

Pal : Mass was not palpable, tenderness (-/-)
Per : CVA (-/-)

Flank Area

Insp: mass (-/-), hematoma (-/-), operation scar (-/-)

Pal : mass was not palpable, tenderness (-/-)

Suprapabic

Ins : bruise (-), hematoma (-), lump (-) Drainage (+) 50cc blood
Pal : vesica urinaria impalpable, mass impalpable tenderness (-)

Genitalia

OUE : bloody discharge (-), edema (-), folley catheter (+)

Penis : edema (-) hematom (-)
Skrotum : edema (-) hematom (-) post surgical scars(-)
Rectal Touche
Anal sphincter tone (strong)
Mucous membrane sleek and smooth
Ampulla recti was not collapsed
Mass was not palpable
Tenderness (-)
BCR (+)
Gloves
Faeces (+) yellow, Blood (-)
Clinical Pictures

A L R CT ECG
Local Status

A L R CT ECG
Laboratory Result April 24th 2015
Items Result Normal Value Unit

Hemoglobine 13,44 14.00 - 18.00 g/dl

Leukocyte 12,2 4.0 10.5 thousand/ul

Eritrocyte 4,48 4.50 6.00 million/ul

Hematocrit 41,3 32.00 44.00 Vol%

Thrombocyte 385 150 450 Ribu/ul

RDW-CV 12,5 11.5 14.7 %

MCV 92,4 80.0 97.0 Fl

MCH 29,9 27.0 32.0 Pg

MCHC 32,4 32.0 38.0 %

A R CT ECG
 Items Result Normal Value Unit

Gran% 80,3 50.0-70.0 %

Lymphosite% 14,6 25.0-40.0 %

MID% 5,1 4.00-11.00 million/ul

Gran# 9,8 2.50-7.00 Billion/ul

Limfosit # 1,8 1.25-4.0 Billion/ul

MID# 0,6 Billion/ul

A R CT ECG
 Items Result Normal Value Unit
GDS 159 <200 Mg/dL

PT 10,8 9,9-13,5 Second

APTT 24,7 22,2-37,0 Second

INR 0,95

SGOT 47 0-46 U/l

SGPT 47 0-45 U/l

Ureum 54 10-50 mg/dL

Creatinin 1,2 0,7-1,4 mg/dL

Natrium 134,9 135-146 mmol/L

Kalium 4,1 3,4-5,4 mmol/L

Chloride 99,8 95-100 mmol/L

A R CT ECG
Thorax X-Ray April 24th 2015

A L CT ECG
BNO X-Ray April 23rd 2015 at Buntok Hospital
Impression:
Suspect Uretrhrolithiasis
DD Prostate calcification

A L CT ECG
Working Diagnosis
Post sectio alta due Urine retention due to
Prostate hyperplasia + HIL dextra reponible

A L R CT ECG
Management
VS Obs
IVFD RL
Inj antibiotic
Inj analgesic
Inj H2Blocker
Complete blood count
Consult to Urology surgeon:
USG Urology
PSA
Consult to Digestive department
Hospitalized
Consult to digestive surgeon:
Treat the HIL first
Planing herniotomy + hernioraphy
A L R CT ECG