REPORT
MAY 15TH
16TH 2017
Chief on Duty :
Julia
Coass on Duty:
Rizal Anshari, Eka, Ayu, Baihaki, Faisal, Ida, Syifa
General Surgery :
4
Digestive Surgery : 1
Thorax Cardiovascular Surgery : 0
Plastic Surgery : 0
Urology Surgery : 1
Neuro Surgery : 2
Pediatric Surgery : 0
Oncology Surgery :
1
Orthopaedy Surgery : 0
Total : 9 patients
Admission to
No Identity Diagnosis Treatment
ER
1 Ch. May 15th 2017 SHI GCS 8 + C Spine control
Rusdianor/15 14.30 wita Diffuse brain Insert OPA
y.o injury Suction
O2 nasal canul
Marshalls class
IVFD NS 18 dpm
IV + depressed Analgetic
fracture of the Antibiotic
frontospenoidal H2 Blocker
dextra Tetanus prophylaxis
communitive Complete blood count
displaced+ Xray Trauma Series
closed fracture CT Scan trauma
Consult to Neuro surgery:
of the right
Informed family about bad
maxilla prognosis
incomplete+ Hopitallized to ICU
Multiple VL and Nimodipine 4x2 tab/ngt if
VE a/r frontalis. theres no resistence.
Manitol 6x100 cc with minimal
BP 110/60.
Consult to plastic sugery:
Hospitallized.
Admission to
No Identity Diagnosis Treatment
ER
2 Ny. Yuliani/40 May 15th 2017 Recurrent O2 Nasal canul
yo 15.00 wita carcinoma IVFD RL 20 dpm
mammae CBC
sinistra post
Consult to Oncology surgery:
MRM on oral Hospitallized
chemotherapy Analgetic
+ Pleural Antibiotic
effusion susp Corcicosteroid
lung
metastases
Karnofsky score
40-50
Admission to
No Identity Diagnosis Treatment
ER
3 Ch. Nazwa May 15th 2017 MHI GCS 15 + Wound toilet
Ramadhan / 16.00 wita Vulnus Wound haecting
10 y.o laceratum ar Skull AP/Lat
frontalis Observation for 6 hours
sinistra
Admission to
No Identity Diagnosis Treatment
ER
4 Mr. Ujang/ 61 May 15th 2017 MHI GCS 14 + IVFD NS 20 dpm
y.o 17.00 wita susp basilar Antibiotic
fracture+ Analgesic
persistent H2 Blocker
cephalgia CT Scan
Discharged by request
Admission to
No Identity Diagnosis Treatment
ER
6 Ms. Febriyani May 15th 2017 Right temporo- Analgetic
L/ 25 y.o 21.30 wita mandubular
joint pain Discharged by permissions
Refer to polyclinic
Admission to
No Identity Diagnosis Treatment
ER
7 Mr. Saili/ 67 May 15th 2017 Working Insert DC
y.o 20.00 wita diagnosis: Discharged by permission
Retentio urine Refer to polyclinic
Etiological
diagnosis: BPH
Complication
diagnosis: -
Additional
diagnosis: -
IPSS 24
Admission to
No Identity Diagnosis Treatment
ER
8 Mrs. Norlian/ May 16th 2017 Chronic IVFD RL 20 dpm
67 y.o 01.30 wita diarrhea + Analgetics
Intrabdominal H2 blocker
mass susp ca CBC
colon
Consult to digestive
surgery:
Hospitallized
Hypochalemia correction
Albumin transfusion
Planned for Colon in loop
Admission to
No Identity Diagnosis Treatment
ER
9 Ms. Rabiatul May 16th 2017 Abdominal pain IVFD RL 20 dpm
Jannah/ 17 y.o 22.30 wita ec susp Analgetics
abdominal CBC (Refused)
msucle strain. Observation for 6 hours.
Discharged by permission
Ch. Rusdianor/15 y.o
Chief Complain:
Decreases of consciousness
History of Current Disease:
Patient became unconsciouss after he had a single
traffic accident using motorcycle. A wittness said he
was riding a motorcyce in a high speed, he was
suddenly unstable, hit a tree, and fell hard to his
right. He didnt used a helmet. There was bleeding
from his right ear and nose. No history of vomitus
and seizure after the trauma. This patient was first
brought to the RS Anshari saleh, they sutured the
PRIMARY SURVEY
A: Gurgling with c spine control
B: RR: 30 tpm, regular, rh(-/-) wh(-/-), SpO2 99% with O2 3 lpm
C: N: 89 bpm, strong, regular, BP: 130/80 mmhg
D: GCS E1V2M5 BH (+/-) BO(+/-) BR (+/-) non active BS (-/-),
pupil anisokhor 4mm/1mm, pupil reflex (+/+) slow responses
to the light.
Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Present illness (-)
L = Last meal 4 hours before accident
E = Environment on the street.
Physical
Examination
Neurology Status
Local status
a/r Frontalis
dextra
L: swelling (+),
hiperemis (+) , multiple
VE, VL 1x2 cm subcutis
based, VL 1x1 cm
subcutis based, VL at
supercilia dextra 8x1
cm sutured.
F: warm (+) crepitation
(-) CRT < 2dtk.
Clinical
picture
Post haecting
Local status
a/r Maxillaris
D
L: swelling (+),
hiperemis (+),
Deformity (-)
F: warm (+) crepitation
(-) CRT < 2dtk.
Local status a/r
Frontosphenoid
dextra
L: swelling (+),
hiperemis (+) , multiple
VE, deformity (-).
F: warm (+) crepitation
(-) CRT < 2dtk.
CXR
Cervical X
Ray
Ap/Lat
CT SCAN
Skull 3D
CT SCAN
Bone window
CT SCAN
Brain window
CT
SCA
N
Brain
window
Complete
blood count
Diagnosis
Karnofsky 40-50
Management
O2 Nasal canul
IVFD RL 20 dpm
CBC
Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Present illness (-)
L = Last meal 2 hours before accident
E = Environment by an unstable decorated fence.
Physical
Examination
Neurology Status
Local status
a/r Frontalis
sinistra
L: swelling (+),
hiperemis (+), VL 3x1
cm fascia based.
F: warm (+)
tenderness (+)
crepitation (-) CRT <
2dtk.
CLINICAL
PICTURE
POST HAECTING
SKULL
AP/LAT
Diagnosis
L: swelling (-),
hiperemis (-), VL 1x1
cm sutured.
F: warm (-) tenderness
(+) crepitation (-) CRT <
2dtk.
CT
SCAN
Bone
window
CT
SCAN
Brain
window
CT
SCAN
SKULL 3D
Diagnosis
Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Present illness (-)
L = Last meal 2 hours before accident
E = Environment On the street.
Physical
Examination
Local status
a/r olecranon
sinistra
L: swelling (+)
hiperemis (+) deformity
(+) wound dehiscence
4x2 cm muscle based.
F: tenderness (+)
crepitation (-) CRT <
2dtk.
M: Limited active and
passive ROM
CLINICAL PICTURE
POST HAECTING
Diagnosis
Wound dehiscence et
causa trauma + susp
elbow dislocation
Managemen
t
Wound toilet
Wound haecting
Tetanus prophylaxis
(refused)
Xray Left elbow
(refused)
Discharged by request
Ms. Febriyani/ 25 y.o
Chief Complain:
Pain when open the mouth
History of Current Disease:
Patient compained about disturbing pain when she open her
mouth, it appears 2 day before the admission, she wasnt sure
about the cause, she just know the pain started after she wakes
up in the morning, so she assumes that it happens when she
sleeps. The pain worsen when she eats or drinks. She also had
history of finger stiff and pain about 2 month before admission,
but it only intermittent. No history of arthritis on her family.
Vital Sign:
BP: 120/70
P: 78 bpm
RR: 18 tpm
Temp: 36.4C
Physical Examination
Local status at
TMJ sinistra
Right
temporomandibular joint
pain
Management
Analgetics
Discharged by permissions
Refer to polyclinic
Mr. Saili/ 67 y.o
Chief Complain:
Cant urinate
History of Current Disease:
Patient cant urinate since 18 hours before admission, before cant urinate,
he compained difficult to urinate since 2 weeks before admission, the
urine were just dropping. He also had to strain to urinate, when the urine
out, stream looks weak. Patient also felt he had to urinate again not long
(about 1-2 hours) after the previous one, espescially at night, it became
more often. He never seen blood on his urine, but cloudy in 1-2 times.
Fever was denied. Patient already diagnosed has BPH since 5 years before
admission, he had the same compain. He routinely using katheter, but he
put off the catheter when he travel to Banjarmasin. The doctor suggest an
operation, but he postponed due to economic reasons.
Vital Sign:
BP: 140/100
P: 80 bpm
RR: 20 tpm
Temp: 36.5C
Physical Examination
Perineum
Ins: Fissura (-) fistula (-) hyperemia (-)
RT:
TSA strong, regular mucosa, palpable mass (-)
Prostate : non palpable upper pole, sulcus medianus
non palpable, enlarged prostate (+) diameter 4 cm
with estimated volume 64 cm3, normal consistency,
smooth surface, tenderness (+) at 12 oclock.
Feses (+) blood (-)
CLINICAL
PICTURE
CLINICAL
PICTURE
Diagnosis
Extremities Warm ekstremities (+) Parese (-) edema grade II (+/+) pitting.
Perineum
Ins: Fissura (-) fistula (-) hyperemia (+)
RT:
TSA less strong , regular mucosa, palpable mass (-),
pain at the 12-14 oclock(+)
Feses (+) blood (-)
CLINICAL PICTURE
USG
Chronic diarrea +
hipoalbuminemia +
hipokalemia +
intraabdominal mass susp ca
colon
Management
IVFD RL 20 dpm
Analgetics
H2 blocker
CBC
I : Distension (-)
A : Bowel sound normal
Abdomen P : tenderness (+) at all region, muscle defans (-), organ
enlargment(-), sign of peritoneal irritability (-)
P : Timpani at all region
Discharged by permission.