Emergency Room

Morning Report
October 16th 2017

Chief on Duty
Rully

Coass on Duty:
Ikka, Rina, Chandra, Neva, Longe, Dara, Nurul,
Ridha.
General Surgery : -

Digestive Surgery :-
Thorax Cardiovascular Surgery :-

Plastic Surgery :-

Urology Surgery :-

Neuro Surgery :
Pediatric Surgery :-

Oncology Surgery :

Orthopaedic :

Total : patients
No Identity Admission to ER Diagnosis Treatment
1. Mrs. Siti October 22nd 2017
Patient
Severe Head Injury + SDH
List
O2 NRM 7 lpm
Nurbaya/75th Admitted: 12.20pm a/r Right and Left Inf NS 30 tpm
Frontoparietal) + SAH + Inj. Omeprazol 1x40 mg
Brain Edema Inj. Ketorolac 3x30mg
Manitol 200cc

Consult to Neurosurgery
Pro Emergency Evacuation
Craniotomy
KIE
Post Op ICU
WB 1 Kolf

-> Patients Family Refused

No Identity Admission to ER Diagnosis Treatment
2. Ch. Ludra Kuzzon/ October 16 th 2017 Perforated Acute
Patient List
IVFD D5 NS 2000/24hour
6 y.o Admitted: 14.10 am Appendicitis Inj. Ceftriaxon 2x1mg
Inj. Ranitidin 2x50 mg
Inj. Ketorolac 3x30 mg
Cbc

Consult to Pediatric Surgery

Pro Emergency Appendictomy
Inf. Metronidazole 3x400mg
PRC 1 Kolf
No Identity Admission to ER Diagnosis Treatment
3. Mrs. Marliana/53 October 16 th 2017
Patient List
Tumor mamae sinistra susp IVFD RL 10 tpm
Y.O Admitted: 16.00 am maligna T3N0M1 (liver, lung, Inj lasix 1-1-0
bone) Inj cefoperazone 2x1gr
KSR tab 1
Epocaldi tab 0-0-1
Inpepsa syr 3x1cth
Durogesic patch /3 hari
Solac syr 1x2cth

Consult to Oncology
Surgery
Stop all injection
Plan for Core Biopsy
Palliative Chemotherapy
No Identity Admission to ER Diagnosis Treatment
4. Ch. M Fariz/14 October 16 th 2017
Patient
Mild Head Injury + susp.
List
IVFD RL 900cc/24hour
months Admitted: 18.00 am Increased Intracranial Hospitalized
Pressure PO
Ibuprofen 3x1cth
Domperidon 2x1cth
if there is no worsening of
condition patient can go home
No Identity Admission to ER Diagnosis Treatment
5. Mr. Aditya Rizky/ October 16 th 2017
Patient
Mild Head Injury + Vulnus
List
IVFD RL 20 dpm
20 y.o Admitted: 20.15 am Laceratum a/r Left Auricula Inj. Ketorolac 3x30mg
et Left Frontal + Vulnus Inj. Ranitidin 2x50mg
Ekskoriatum a/r Left
Zygomaticum Consult to Plastic Surgery
No Identity Admission to ER Diagnosis Treatment
6. Mrs. Siti October 16 th 2017
Patient List
Closed Fracture of Left IVFD RL 20 dpm
Nurbaya/75 y.o Admitted: 21.35 am Superior and Inferior Inj. Ketorolac 3x30mg
Pubic Rami Inj. Ranitidin 2x50mg
Pelvic Wrap
Wound Hecting

Consult to Orthopedy
Conservative Treatment with Bed
Rest for 2 weeks
PO
Mefenamic Acid 3x500mg
Ranitidin 2x50mg
Calcium 2x500mg
 1. Mrs. Siti Nurbaya/75 y.o

Chief Complain:
Decreased of Consciousness
History taking:
Patient has decreased of consciousness since 6 hours before admission,
suddenly after patient had traffic accident earlier. Patient was walking and then hit
by motorcycle, no one knows the exact mechanism of the incident. Vomiting (-),
bleeding from the left ear (+), mouth (+), nose (-), seizures (-). Patient is a referral
from Suaka Insan Hospital with diagnosis of Severe Head Injury + EDH + SAH + SDH
Patients was referred for reason to use BPJS and have ordered ICU in RSUD ULIN

Past Ilnessess DM(-) HT (+) Asthma (-)

Primary survey

A: Clear, with C-spine control

B: RR: 20x/mnt, reguler, rh(-/-) wh(-/-), SpO2 97% O2 NRM 7lpm
C: HR: 97x/mnt, Reguler, Strong BP: 130/80mmHg
D: GCS E1V1M3 Anisochor Pupil (3mm/4mm) LR (+/-), BH (-/-) BS(-),
BR(-/-), BO(-). Lateralization (-).
 Secondary survey

A: Allergy (-)
M: Medication (-)
P: (-)
L: 4 hours
E: On the road
Physical Examination
Head : Pale conjunctiva (-|-) light reflex (+|-), Edema palpebra (-/-),
Head Mouth : Moist mucous membrane
Neck : Increased level of JVP (-), laceration (-) tenderness(-)

I : symmetrical respiratory movement, retraction (-),

P : Symmetric VF
Chest P : Sonor at all regio
A : symetric VS, no ronchi, no wheezing

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

A : Bowel sound (+) normal
Abdomen P : defence muscular (-)
P : timpani at all regio

Extremities warm extremities

Working Diagnosis
Severe Head Injury + SDH a/r Right and Left
Frontoparietal) + SAH + Brain Edema
Management
O2 NRM 7 lpm
Inf NS 30 tpm
Inj. Omeprazol 1x40 mg
Inj. Ketorolac 3x30mg
Manitol 1x200cc loading dose

Consult to Neurosurgery
Pro Emergency Evacuation Craniotomy -> Patients Family Refused
KIE , Post Op ICU ,WB 1 Kolf

Patient admitted to ICU -> + manitol 4x125cc

 2. Ch. Ludra Kuzzon/ 6 y.o

Chief Complain:
Abdominal Pain

History taking:
Patients complain of lower right abdominal pain since 1 day ago. Pain felt like such being
stabbed. Patient also felt nausea and vomiting 4 times. Patient had decreased of appetite and
had not defecate chapter since 2 days ago. Patients have done ultrasound in Sari Mulia
Hospital on 22/10/2017 with the result of ultrasound appendicitis acuta with peritoneal
reaction toward peritonitis generalize

Family history of ilness (-)

Past Ilnesses : Asthma (-)
Vital Sign
GCS 15 E4V5M6
CRT 2s
HR: 105 x/m
RR: 24 x/m
T: 37.0 C
SpO2: 98 % without O2
Physical Examination
Head : Pale conjunctiva (-|-) light reflex (+|+), Edema palpebra (-/-),
Head Mouth : Moist mucous membrane
Neck : Increased level of JVP (-), laceration (-), enlargement of lymph node (-)

I : symmetrical respiratory movement, retraction (-),

P : Symmetric VF
Chest P : Sonor at all regio
A : symetric VS, no ronchi, no wheezing
I : distension (-) Venectation (-)
A : Bowel sound (+) Decreased
Abdomen P : defence muscular (-) tenderness in McBurney (+) , Rovsing (+), Blumberg (+),
Psoas (+), Obtutaror (+)
P : timpani at all regio

Extremities warm extremities

 Rectal Touche
TSA Clamp Stronglu, Rectal Ampoule
Uncollapse, Smooth mucosa, Tenderness in
6 oclock.
Handscoon : Fecess (+), Blood (-)
 Working Diagnosis
Perforated Acute Appendicitis
 Management
Inf. D5 1/2 NS 1890 / 24 Hour
Inj. Cefotaxim 2x1 gr
Inj. Ranitidin 2x1/2 amp
Inj. Ketorolac 3x15 mg

Consult to Pediatric Surgery:

Pro Emergency Appendictomy
 3. Mrs. Marliana/53 Y.O

Chief Complain:
Weakness
History taking:
Patient complains of weakness since 5 days before admission. Patients also complain
about the decrease of appetite since the 5th day ago, the patient eat less since then.
Nausea (+) vomiting (-). Patients also complained of a lump in the left breast since 5 years
ago, initially as big as a marble then within 5 years to as big as a softball. Pain (-), bloody
discharge(-). patients forget the age of menarche, Patient is 3 years of menopause. Birth
history (-), history of breastfeeding (-), history of oral contraceptives and routine injections
(-). History exposed to radiation (-). Patients complain about shortness of breath from 10
days of smrs, dizziness (+) since 3 days of smrs, nausea vomiting (-), Feeling full at right
abdomen (+), spinal pain (+) History of weight loss is denied. History of fever (-). No family
history of similar complaints. Patient was reffered from Bayangkara Hospital with the
diagnosis of Ca Mammae T3NxM1.
Vital Sign
GCS E3V5M6
BP: 130/90
HR: 110x/mnt
RR: 22x/mnt
T: 37,5C
SpO2: 99% O2 NC 2lpm
Physical Examination
Head : Pale conjunctiva (-|-) light reflex (+|+), Edema palpebra (-/-),
Head Mouth : Moist mucous membrane
Neck : Increased level of JVP (-), laceration (-), enlargement of lymph node (-)

I : symmetrical respiratory movement, retraction (-),

P : Symmetric VF
Chest P : Sonor at all regio
A : symetric VS, no ronchi, no wheezing

I : distension (-) Venectation (-)

A : Bowel sound (+) Normal
Abdomen P : defence muscular (-) tenderness (-)
P : timpani at all regio

Extremities warm extremities

Status lokalis a/r
mammae dextra:
L: ulkus(-
)hiperpigmentasi(-)
produksi pus (-),
perdarahan aktif (-),
retraksi nipple(-)

F: massa solid, batas

tegas, mobile, ukuran
5x4cm, nyeri (-)
Working Diagnosis

Tumor mamae sinistra susp maligna T3N0M1 (liver, lung, bone)

Treatment
IVFD RL 10 tpm
Inj lasix 1-1-0
Inj cefoperazone 2x1gr
KSR tab 1
Epocaldi tab 0-0-1
Inpepsa syr 3x1cth
Durogesic patch /3 hari
Solac syr 1x2cth
Consult to Oncology Surgery
 4. Ch. M Fariz/14months

Chief Complain:
Vommiting
History taking:
Patients complained of vomiting since 8 hours before admission.
Patient vommited 6 times. The vommit was spraying and food content.
Patient was fell into the floor 8 hours ago, the rear head bumped on the
floor. Seizures (-) Fainting (-) blood out of ear (-), nose (-), mouth (-) Cold
(+) cough (+) Fever (+) since 1 day ago. Patient was initially Pediatric
patient and consulted to Neurosurgery with Susp of Increased
Intracranial pressure.
Primary survey

A: Clear, with C-spine control

B: RR: 28x/mnt, reguler, Strong, rh(-/-) wh(-/-), SpO2 98%
C: HR: 126x/mnt, CRT 2s
D: GCS E4V5M6. Isochor Pupil (3mm/3mm) LR (+/+)BH (-/-) BS(-/-),
BR(-/-), BO(-/-) Lateralization (-).
 Secondary survey

A: Allergy (-)
M: Medication (-)
P: (-)
L: 8 hours
E: House
Physical Examination
Head : Pale conjunctiva (-|-) light reflex (+|+), Edema palpebra (-/-),
Head Mouth : Moist mucous membrane
Neck : Increased level of JVP (-), laceration (-), enlargement of lymph node (-)

I : symmetrical respiratory movement, retraction (-),

P : Symmetric VF
Chest P : Sonor at all regio
A : symetric VS, no ronchi, no wheezing

I : distension (-) Venectation (-)

A : Bowel sound (+) Normal
Abdomen P : defence muscular (-) tenderness (-)
P : timpani at all regio

Extremities warm extremities

Working Diagnosis
Mild Head Injury + susp. Increased Intracranial
Pressure
Management
IVFD RL 900cc/24hour
Hospitalized
PO
Ibuprofen 3x1cth
Domperidon 2x1cth
if there is no worsening of condition patient can go home
 5. Mr. Aditya Rizky/ 20 y.o

Chief Complain:
Wound on the forehead
History taking:
The patient came with a wound on the forehead since 5 hours before admission.
Previously the patient fell off the motorcycle. The patient's head hits the ground.
Patients do not use helmets, dizziness (+). Patients also complained of tear lesions in
the upper left ear. Previously, the wound on the forehead of the patient has been
cleansed and covered in the clinic in Tanah Bumbu before the patient wass referred
to Ulin Hospital. The wound on the forehead is actively bleeding. History of fainting (-
) nausea (-), vomiting (-), blood out of ear (-), nose (-), mouth (-).

Past Ilnessess : Asthma (-)

Primary survey

A: Clear, with C-spine control

B: RR: 20x/mnt, reguler, rh(-/-) wh(-/-), SpO2 99% w/o O2
C: HR: 96x/mnt, Reguler, Strong BP: 110/70mmHg
D: GCS 15 E4V5M6 Isochor Pupil (3mm/3mm) LR (+/+), BH (-/-) BS(-),
BR(-/-), BO(-). Lateralization (-).
 Secondary survey

A: Allergy (-)
M: Medication (-)
P: (-)
L: 8 hours
E: On the road
Physical Examination
Head : Pale conjunctiva (-|-) light reflex (+|+), Edema palpebra (-/-),
Head Mouth : Moist mucous membrane
Neck : Increased level of JVP (-), laceration (-), enlargement of lymph node (-)

I : symmetrical respiratory movement, retraction (-),

P : Symmetric VF
Chest P : Sonor at all regio
A : symetric VS, no ronchi, no wheezing

I : distension (-) Venectation (-)

A : Bowel sound (+) Normal
Abdomen P : defence muscular (-) tenderness (-)
P : timpani at all regio

Extremities warm extremities

Status lokalis a/r auricula sinistra
L: Vulnus laceratum pada preauricula hingga posterior auricula setinggi
procesus mastoid, tulang rawan auricula terekspos pada bagian posterior
auricula, perdarahan inaktif . Struktur tulang rawan helix terputus pada crux
helix.
F: Nyeri tekan (+)

Status lokalis a/r frontal

L: Vulnus laceratum pada regio frontal sinistra, Di sisi superior lateral dari
eyebrow, tepi luka ireguler, dasar luka fascia, perdarahan inaktif.
F: Nyeri tekan (+)

Status lokalis a/r zygomatic sinistra

L: Vulnus ekskoriatum 5x4cm, perdarahan (-)
F : nyeri tekan (+)
Working Diagnosis
Mild Head Injury + Vulnus Laceratum a/r Left Auricula
et Left Frontal + Vulnus Ekskoriatum a/r Left
Zygomaticum
Management
Consult to Plastic Surgery
 6. Mrs. Siti Nurbaya/75 y.o

Chief Complain:
Pain in left thigh
History taking:

Patient complaint of pain in left thigh since 30min before admission. Patients
experience KLLD, hit by a motorist as the patient walks. The patient can not move
the left and right legs. The left leg is more sore than the right foot. There is no injury
to the left thigh, right thighs are injured (+), nausea (-), vomiting (-), fainting (-),
seizures (-), dizziness (+)

Past Ilnessess DM(-) HT (-) Asthma (-)

Primary survey

A: Clear, with c spine control

B: RR: 24 x/mnt, reguler, rh(-/-) wh(-/-), SpO2 98% w/o O2
C: HR: 80 x/mnt, strong, reguler, BP : 120/80 MmHg
D: GCS 15 (E4V5M6), Isochor Pupil (3mm/3mm) LR (+/+)BH (-/-) BS(-
/-), BR(-/-), BO(-/-) Lateralization (-).
 Secondary survey

A: Allergy (-)
M: Medication (-)
P: (-)
L: 4 hours
E: On the road
Physical Examination
Head : Pale conjunctiva (-|-) light reflex (+|+), Edema palpebra (-/-),
Head Mouth : Moist mucous membrane
Neck : Increased level of JVP (-), laceration (-), enlargement of lymph node (-)

I : symmetrical respiratory movement, retraction (-),

P : Symmetric VF
Chest P : Sonor at all regio
A : symetric VS, no ronchi, no wheezing

I : distension (-) Venectation (-)

A : Bowel sound (+) Normal
Abdomen P : defence muscular (-) tenderness (-)
P : timpani at all regio

Extremities warm extremities

Working Diagnosis

Closed Fracture of Left Superior and Inferior Pubic Rami

Management
IVFD RL 20 dpm
Inj. Ketorolac 3x30mg
Inj. Ranitidin 2x50mg
Pelvic Wrap
Wound Hecting
Consult to Orthopedy
Conservative Treatment with Bed Rest for 2 weeks
PO
Mefenamic Acid 3x500mg
Ranitidin 2x50mg
Calcium 2x500mg
Thank You