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Emergency Report

Januari 01th 2019


Co-ass on duty:
Mu’izzadin Hasani
Gita Febriany
General Surgery : 1

Digestive Surgery : -

Urology Surgery : -

Neuro Surgery : -

Oncology Surgery : -

Orthopaedy : 1

Total : 2
Patient List
No Identity Admission to ER Diagnose Treatment

1. Tn. Sarinoe /50 y.o./ Jan 01th 2019 Vulnus Sclopetorum VS Obs
RM. 31.12.88 14.30 Regio Thoracal (S) IVFD RL
Pneumotorax (S) Cek DL
Emfisema Subkutis Analgetic
Thorax x-ray

Co to Sp.B :
-Pro WSD  Rujuk ke
Banjarmasin.
- Inj Tramadol 100mg
- Inj Ceftriaxone 1gr
- Inj Tetagam 250 IU
Patient List
No Identity Admission to ER Diagnose Treatment

2. NY. Silvia/ 31 y.o Jan 01th 2019 Close Fracture Tibia (D) VS Obs
RM 31.12.96 16.20 WIB Vulnus Excoriasi IVFD RL
Analgetic
xray

Consult to orthopedic
- Spalk
- Kompres
- Inj. Ketorolac
3x30mg
NY. Silvia/ 31 y.o
RM 31.12.96

Chief Complain:
Nyeri dan bengkak pada kaki kanan.

History of Current Disease:


Pasien post KLL 5 jam SMRS, pasien mengaku sempat
pingsan 5 menit setelah terjatuh dr motor, kejang (-),
muntah (-), perdarahan (-). Pasein mengeluh nyeri pada kaki
kanan. Selain itu pasien mengeluh pusing, berputar (-).
Primary survey :
A : Clear without c-spine control
B : RR 20x/m, symmetrical shape
C : BP: 120/80 HR : 98x/m;
D : GCS 15 E4V5M6, pupil round equal Ø 3 mm, light reflex +/+
lateralization (-) , BH(-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 2 hours before accident
E = Environment  on the street.
• Head : brill haematoma( -/-), hematoma (-)
• Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head • Mouth : moist mucous membrane,
• Neck : Increasion level of JVP (-)

General Status
• I : symmetric respiratory movement, no retraction, bruises (-)
• P : symmetric VF
Chest • P : sonor at all lung fields
• A : symmetric VBS, right =left, rhonchi (-), wheezing (-)

• I : distension (-), bruises (-)


• A : normal Bowel sound
Abdomen • P : defence muscular (-) tenderness (-) , rebound tenderness
(-)
• P :Thymphani (+)

• warm extremities,CRT<2 sec edema (-), parese (-), see local


Extremities status
Local status
a/r Left Leg
• Swelling /bengkak (+), deformity (-) wound (-),
L tampak kemerahan.

• Tenderness / nyeri tekan (+), distal neurovascular


F (+). A.tibialis post (+), A. Dorsalis pedis (+)

• ROM active and passive limited due to pain


M
• Motoric status :
Superior : 5 II 5
Inferior : 2 II 5
• Sensoric status : + II +
Clinical picture
Cruris Xray
Laboratory
Examination Result Normal value
Hemoglobin 14,4 11.00-5.00 g/dl
Leukocyte 15,54 4.0-10.0 Thousand /ul
Erythrocyte 4,97 3.50-5.00 milion /ul
Hematocrite 43.5 37.00-47.00 Vol%
Platelets 230 150-450 Thousand /ul
Blood glucose 96 90-200 mg/dL
AST - 0-46 U/I
ALT - 0-45 U/I
Urea 35 21-53 Mg/dL
Creatinine 0,79 0.7-1.5 Mg/dL
Working Diagnosis

Closed Fracture of Right Tibia


Vulnus Ekskoriasis
Management
•VS Obs
•IVFD RL
•Analgetic
•xray

•Consult to orthopedic
- Spalk
- Kompres
- Inj. Ketorolac 3x30mg
Tn. Sarinoe /50 y.o./
RM. 31.12.88

Chief Complain:
Tertembak Senapan angin.

History of Current Disease:


Pasien post tertembak senapan angin di dada kiri, os
mengeluh sesak nafas dan nyeri pada dada kirinya. Os
mengeluh berat ketika bernafas. Sesak baru dirasakan ketika
sehabis tertembak. Sesak tidak dipengaruhi oleh aktifitas
dan cuaca.
Primary survey :
A : Clear without c-spine control
B : RR 25x/m, symmetrical shape (-)
C : BP: 90/70 HR : 104x/m;
D : GCS 15 E4V5M6, pupil round equal Ø 3 mm, light reflex +/+
lateralization (-) , BH(-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 4 hours before accident
E = Environment  on the home.
• Head : brill haematoma( -/-), hematoma (-)
• Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head • Mouth : moist mucous membrane,
• Neck : Increasion level of JVP (-)

• I : asymmetric respiratory movement ( ketertinggalan gerak


General Status (S) ) , no retraction, bruises (-), vulnus sklopetorum (+)
Chest • P : asymmetric VF ( menurun pada paru kiri)
• P : sonor at all lung fields
• A : symmetric VBS, right =left , rhonchi (+) S, wheezing (-)

• I : distension (-), bruises (-)


• A : normal Bowel sound
Abdomen • P : defence muscular (-) tenderness (-) , rebound tenderness
(-)
• P :Thymphani (+)

• warm extremities,CRT<2 sec edema (-), parese (-), see local


Extremities status
Local status

• Tampak ketertinggalan gerak dada kiri.


L Vunlus sklopetorum (+).

• Tenderness / nyeri tekan (+), krepitasi


F (+)

• Ketertinggalan gerak dada kiri.


M
Clinical picture
Thorax Xray
Laboratory
Examination Result Normal value
Hemoglobin 11,7 11.00-5.00 g/dl
Leukocyte 15,70 4.0-10.0 Thousand /ul
Erythrocyte 3,84 3.50-5.00 milion /ul
Hematocrite 32.1 37.00-47.00 Vol%
Platelets 211 150-450 Thousand /ul
Blood glucose 99 90-200 mg/dL
AST - 0-46 U/I
ALT - 0-45 U/I
Urea 32 21-53 Mg/dL
Creatinine 1,37 0.7-1.5 Mg/dL
Working Diagnosis

Vulnus Sclopetorum Regio Thoracal (S)


Pneumotorax (S)
Emfisema Subkutis
Management
•VS Obs
•IVFD RL
•Cek DL
•Analgetic
•Thorax x-ray

•Co to Sp.B :
•-Pro WSD  Rujuk ke Banjarmasin.
- Inj Tramadol 100mg
- Inj Ceftriaxone 1gr
- Inj Tetagam 250 IU