Emergency Room

Morning Report
August 7 th 8 th 2017

Chief on Duty
Evania

Coass on Duty:
Rangga, Chyntia, Dwi Putri, Ridma, Rahmi,
Ketty, Ihda
General Surgery :-

Digestive Surgery :1

Thorax Cardiovascular Surgery :-

Plastic Surgery :-

Urology Surgery :-

Neuro Surgery :2

Pediatric Surgery :1

Oncology Surgery :-

Orthopaedic :1

Total : 5 patients
No
1.
Identity Admission to ER
Mr. M. Ilyas/62 yo August 7th 2017
Patient
Diagnosis
Multiple abcess
List Treatment
Treatment from RS Kotabaru:
No Identity Admitted: 21.00 tohepar
Admission ER Diagnosis Inj. Ceftriaxone 2x1 gr
Treatment
Hospitallized: IVFD Metronidazole 3x500 mg
4. Mr. Tusin M/82 July 11th 2017 Clinical: gross IVFD NS 0,9% 20 dpm
23.20 IVFD PCT 1x500 cc
yo hematuria 3-way urine catheter insertion
IVFD Aminoleban 20 tpm
(spooling)
Etiological: BPH Inj. Ketorolac 2x30 mg
dd prostate PO. Curcuma 1x1 tab
malignancy
Co urology surgery
Additional: Co. Digestive surgery at 21.30 pm:
- Hospitalization
Anemia Hospitalized
- PRC transfusion 2 units/day
Complication: - CT Scan abdomen at room
No Identity Admission to ER Diagnosis Treatment
2. Ch. Cahaya August 7th 2017 Acute appendicitis Check lab DR, PT/APTT, Na/K/Cl
Redha Admitted: 21.45 IVFD Rl 20 tpm
Inj. Antrain 50 mg (k/p)
Inj. Ranitidin 2x1/2 amp (k/p)
No Identity Admission to ER Diagnosis Treatment
3. Mrs. Siti August 7th 2017 Wound bleeding post O2 nasal canule 2 lpm
Masitah/60 yo Admitted: 16.00 op debridement + IVFD Ns 20 tpm
OREF + ORIF Inj. Tranexamat acid 3x500 mg
Check lab DL
Wound toilet + dressing

Co. Orthopedi at 16.30:

Skin traction
Transfusion PRC 2 kolf
Control at polyclinic orthopedi:
Cefadroxil 2x1 tab
Diclofenac 2x1 tab
Ranitidin 2x1 tab
Tranexamat acid 2x1 tab
No Identity Admission to ER Diagnosis Treatment
4. An. Ramdan/8 yo August 8th 2017 CKR GCS 14 + Tx from RSUD Tanah Bumbu:
Admitted: 05.30 fracture depressed O2 2 lpm
occipital dextra IVFD Ns 15 tpm
Inj. Ceftriaxone 2x2500 mg
Inj. Ranitidin 2x25 mg
Inj. Ketorolac 3x10 mg
Inj. Ondancentron 3x3 mg
Check lab DL

Co. Neurosurgery:
Craniotomy elevation electif
No Identity Admission to ER Diagnosis Treatment
5. Mr. Suci August 8th 2017 CKS GCS 9 + close Tx from Doris Sylvanus Hospital:
Handoko/34 yo Admitted: 06.15 fracture femur 1/3 O2 NRM 15 lpm
media dextra et IVFD NS 20 tpm
sinistra + close Inj. Ceftriaxone 2x1 gr
fracture ulna 1/3 Inj. Ketorolac 3x30 mg
proximal + close Inj. Ranitidin 2x50 mg
fracture olecranon
1/3 media Co. neurosurgery:
Check lab DL
Head CT Scan
 1. Mr. M. Ilyas/ 62 yo
Chief Complain:
Abdominal pain
History taking:
Patient complained of lower left abdominal pain since three days before admission. Abdominal
pain appears sudden and disappear. Abdominal pain like being stabbed with pain scale 8/10.
Patient complained of fever since two days ago. Anorexia (+), BAB (+), BAK (+) with urine color
like tea since one day before admission. History of illness: hemorrhoid (+) since five years ago.

PMH: HT (-), DM (-)

Vital Sign
GCS E4V5M6
BP: 110/70 mmHg
HR: 87 bpm, strong pulse
RR: 20 rpm
T: 36.7C
SatO2 99% without supply O2
Physical Examination
Head: Pale conjunctiva(-/-), jaundice sclera (-/-), pupil isocor (3mm/3mm), light reflex
(+/+)
Head Mouth : Moist lips mucosa
Neck : Increased level of JVP (-), laceration (-)

I : symmetrical respiratory movement, retraction (-)

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

I : distension (-)
A : Normal Bowel sound
Abdomen P : tenderness (+) of the left lumbal, palpable enlargement of the liver in the left lobe
P : tympani

Extremities warm extremities

 I: mass (-), stool brownish
green
P: Sphincter ani clamping
strongly, ampula rekti not
collapsed, palpable mass
direction at 6 o'clock
Working Diagnosis

Multiple abcess hepar

Management
Treatment from RSUD Kotabaru: Co. Digestive surgery:
Inj. Ceftriaxone 2x1 gr Hospitallized
IVFD Metronidazole 3x500 mg CT Scan abdomen at room
IVFD PCT 1x500 cc
IVFD Aminoleban 20 tpm
Inj. Ketorolac 2x30 mg
PO. Curcuma 1x1 tab
 2. Ch. Cahaya Redha/14 yo
Chief Complain:
Abdominal pain
History taking:
Patient come to hospital with families with abdominal pain complaint since 4 days before
admission. Pain appears suddenly and arise in the lower right abdomen so that the patient
is walking bowed, the pain spread to other stomach part denied by the patient. Pain as
stabbed, with pain scale 5/10. Patient also complain of fever that disappeared and
sometimes accompanied by chills since 4 days ago. Patient also feel nausea and sometimes
vomiting 4 times since 4 days ago and last vomiting yesterday afternoon before admission.
The vomit usually contains fluid, the color of the liquid is forgotten. BAB (+) is slightly fluid
yellow, BAK (+).
Vital Sign
GCS E4V5M6
BP: 90/60 mmHg
HR: 92 bpm, strong pulse
RR: 22 rpm
T: 36.1C
SatO2 98% without supply O2
Physical Examination
Head : Pale conjunctiva (+/+), jaundice sclera (-/-), pupil isocor (3 mm/3 mm), light
reflex (+/+)
Head Mouth : Moist lips mucous
Neck : Increased level of JVP (-), laceration (-), enlarged lymph node (-)

I : symmetrical respiratory movement, retraction (-), bruise(-)

P : symmetrical VF
Chest P : Sonor at all lung fields
A : Symmetrical vesicular, no ronchi, no wheezing
I : distension (-)
A : Bowel sound (+)
Abdomen P : defence muscular (-) tenderness (+) at Mc Burney, psoas sign (-), rovsing sign (-),
obturator sign (+)
P : Tympani (+)

Extremities warm extremities.

 I: mass (-), slick rectal
mucosa, brownish brown
feces
P: Sphincter ani clamping
strongly, ampula rekti not
collapsed
USG abdomen 7 August 2017:
USG acute appendicitis
Working Diagnosis

Acute appendicitis
Management
Co. Pediatric surgery at 22.45:
IVFD Rl 20 tpm
Cito appendectomy
Inj. Antrain 500 mg (k/p)
Inj. Ranitidin 2x25 mg (k/p) The patient family asked to move to another
hospital for an appendectomy
 3. Mrs. Siti Masitah /60 yo

Chief Complain:
Wound surgery seeps
History taking:
The patient came with a former surgical complaint seeping out of blood
since 1 hour before admission. Patient history of surgery 12 days ago at
Ulin hospital, due to traffic accident. The patient's left arm is broken and in
fixation. Previously the wound had seeped 1 week ago and was taken to
the emergency room Ulin hospital but was unable to take action and the
patient advised control to the polyclinic.
Vital Sign
GCS E4V5M6
BP: 110/70 mmHg
HR: 82 bpm, strong pulse
RR: 20 rpm
T: 36.1C
SatO2 98% without supply O2
Physical Examination
Head : Pale conjunctiva (+) pupil isocor (3 mm/3 mm), light reflex (+/+)
Head Mouth : Moist lips mucous
Neck : Increased level of JVP (-), laceration (-), enlarged lymph node (-)

I : symmetrical respiratory movement, retraction (-)

P : Symmetrical VF,
Chest P : Sonor at all lung fields
A : symmetrical VBS, no ronchi, no wheezing

I : distension (-)
A : Bowel sound (+)
Abdomen P : defanse muscular (-)
P : Tympani (+)

Extremities warm extremities

Localis status at regio antebrachii sinistra
L: elastic bandage (+), blood seeps (+), OREF (+)
F: tenderness (+), crepitation (+)
M: limited due to pain
Clinical picture
Working Diagnosis

Wound bleeding post op debridement + OREF + ORIF

Treatment
O2 nasal canule 2 lpm
IVFD Ns 20 tpm
Inj. Tranexamat acid 3x500 mg
Check lab DL
Wound toilet + dressing

Co. Orthopedi at 16.30:

Skin traction
Transfusion PRC 2 kolf
Control at polyclinic orthopedi:
Cefadroxil 2x1 tab
Diclofenac 2x1 tab
Ranitidin 2x1 tab
Tranexamat acid 2x1 tab
 4. Ch. Ramdan / 8 yo

Chief Complain:
Decrease of consciousness
History taking:
Patient have decreased consciousness since 9 hours of SMRS. Patient fell as he
stepped off the motor and the rear head hit a high drainage limit. Helmet (-).
Fainting (+), then conscious and disconnected when invited communication.
Vomiting (+) 6x, yellow vomiting, nose bleeding and ear (-), seizures (-).
Vital sign
GCS E3V5M6
BP : 110/70 mmHg
HR : 87 x/m
RR : 24 x/m
T : 36,3C
SpO2 : 99% with O2 nasal canule 2 lpm
Mini Neurologyc :

GCS E3V5M6
Light reflex (+/+) 3 mm/3 mm
isokor.
cornea reflex (+/+)
BH/BS/BO/BR (-/-/-/-)
Lateralisasi (-/-)
Physical Examination
Head : Pale conjunctiva (-/-) pupil isokor (3 mm/3 mm), light reflex (+/+), Edema
palpebra (-/-),
Head Mouth : Moist lips mucous
Neck : Increased level of JVP (-), laceration (-), enlargement of lymph node (-)

I : symmetrical respiratory movement, retraction (-), bruise(-)

P : Symmetrical VF
Chest P : Sonor at all lung fields
A : symmetrical VBS, no ronchi, no wheezing

I : distension (-) wound (-) hematoma(-) lacerated (-)

A : Bowel sound normal
Abdomen P : defence muscular (-) tenderness (-) mass (-)
P : Tympani (+)

Extremities warm extremities

Working Diagnosis

CKR GCS 14 + Fracture depressed occipital

Management
Tx from RSUD Tanah Bumbu:
O2 2 lpm
IVFD Ns 15 tpm
Inj. Ceftriaxone 2x2500 mg
Inj. Ranitidin 2x25 mg
Inj. Ketorolac 3x10 mg
Inj. Ondancentron 3x3 mg
Check lab DL

Co. Neurosurgery:
Craniotomy elevation electif
 5. Mr. Suci Handoko / 34 yo
Chief Complain:
Decreased of conciousness
History taking:
Patient had an accident since Wednesday at 10 pm and crashed into a parking truck. Patient
was treated at Doris Sylvanus Hospital for 5 days. Vomiting (-) seizures (-) fainting (-).
Patient had decreased consciousness since Monday at 19:00 and patient was referred
to Ulin Hospital for CT head scan.
 Primary Survey
O)
A: not clear, without c spine control
B: RR: 30 tpm, regular, rh(+/+) wh(-/-), SpO2 100% with O2
NRM 15 lpm
C: N: 120 bpm, regular, strong, TD 100/70 mmHg
D: GCS 9 (E3V2M4), BH (+/+) BS(-/-), BO(-/-), BR (-/-)
Mini neurology

GCS E3V2M4 (9)

Pupillary reflex +/+, anisochor
(2 mm/5 mm)
Lateralization (-)
BH (+) BS (-) BR (-) BO (-)
Physical Examination
Head : Pale conjunctiva (-/-), anisocor pupil (2 mm/5 mm), light reflex (+/+), cornea
reflex (+/+)
Head Mouth : Moist lips mucous
Neck : Increased level of JVP (-), laceration (-), enlarged of lymph nodes (-)

I : symmetrical respiratory movement, retraction (-)

P : Symmetrical movement, symmetric fremitus tactile
Chest P : Sonor at all lung fields
A : symmetrical VBS, ronchi (+/+), no wheezing

I : distension (-) wound (-) hematoma(-) lacerated (-)

A : normal bowel sound
Abdomen P : muscular defans (-) tenderness (-) mass (-)
P : Tympani (+)

warm extremities
Extremities Edema (-)
Working Diagnosis

CKS GCS 9 + close fracture femur 1/3 media dextra et sinistra +

close fracture ulna 1/3 proximal + close fracture olecranon 1/3
media
Management
Tx from Doris Sylvanus Hospital:
O2 NRM 15 lpm
IVFD NS 20 tpm
Inj. Ceftriaxone 2x1 gr
Inj. Ketorolac 3x30 mg
Inj. Ranitidin 2x50 mg

Co. neurosurgery:
Check lab DL
Head CT Scan
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