Emergency Report

May 25th -26th, 2014

Resident on duty:
Dr. Immanuel Hendro
Chief on duty:
Sari
Co-Ass on duty:
Redha, Fath, Ferisa, Shinta, Fatimah, Zainul

PATIENT LIST
Oncology surgery

Patients List
No

Identity

Admission to
E.R.

Diagnosis

1. Ms.Masjuda June 30th, Hemiparese

dextra ec. SH
h/ 73 yo
2014 at
03.35 p.m

Management

Consulted neuro surgeon:

Evacuation Craniotomiy

Patients List
No

Identity

2. Ms.
Suminah/
50 yo

Admission to
E.R.

June 30th,
2014 at
07.00 p.m

Diagnosis

Management

Mild head injury

(GCS E3V5M6)
+ zygoma
dextra fracture
+ zygomaxilla
sinistra fracture
+ dentoalveolar
maxilla fracture
+ dentoalveolar
mandibula
fracture + susp.
infra cochlear
tibia fracture

IVFD line
Head up 300
O2 NRM 10lpm
Blood Check
X-ray:cruris sinistra
CT Scan
Analgesic
Antibiotic
H2 Blocker
Rehecting a/r supra orbita sinistra & mandibula
Consulted to Neuro surgeon:
Hospitalized
Observation of elevated intracranial pressure
symptoms
Consulted to Plastic surgeon
Consulted to Plastic surgeon :
Betadine gargle 3t/day
Gentamicin zalf
Liquid diet
Pro orif elective

Patients List
No

Identity

Admission to
E.R.

Diagnosis

Acute
3. Mr.Muhama July 1th,
Appendicitis
d Nur/ 29
2014 at
yo
02.10 a.m

Management

Blood Check
Thorax X-Ray
IV Line
H2blocker
Fasting
USG Appendix
Consulted digestive surgeon:
Pro appendectomy

1. Ms.Masjudah/ 73 yo/ June 30th, 2014 at 03.35 p.m

Chief complain: Decrease of consciousness

History :
Patient came to the hospital with main complain was
decrease of consciousness since 24 hours before
admission. As for this moment patient fully awake but
she cant speak. Patient had history of stroke 10 years ago
and had weakness at right side of the body. History of
hipertention was unknown.

List of patient

General Status
Awareness: alert
GCS15 : E4VxM6
Vital sign
BP : 150/100 mmHg
HR : 88 t/m
RR : 26 t/m
T : 37,1 oC

List of patient

Physical Examination
Head/Neck

List of patient

List of patient

Laboratory Findings

Hb: 11,3
WBC : 12,6
RBC : 4,07
Hematocrite : 34,2
Plt : 269
BSR : 135
SGOT/SGPT: 32/14
Ur/Cr:35/0,6

Na: 141,4
K : 3,7
Cl : 104,1

List of patient

Head CT-Scan

List of patient

Working Diagnosis
Hemiparese dextra ec. SH

List of
patient

Management
Consulted to Neuro surgeon:
Evacuation Craniotomy

List of patient

2. Ms. Suminah/ 50 yo/June 30th, 2014 at 07.00 p.m

Chief complain: Decrease of consciousness

History :
7 hours before admission patient was riding a
motorcycle, then patient hi another car from the opposite
direction. Patient was wearing a helmet but patient hed
history of passing out, bleeding from ear (-), nose (-),
mouth (-). Patient was then brought to RSUD Hadji
Boejasin Pelaihari and during the time there was no
history of vomiting. Patient was referred to Ulin General
hospital further treatment. Patient also complain about
pain at face, mouth area and her teeth.
List of patient

Primary Survey

List of patient

On the road

List of patient

Physical Examination
Head/Neck

List of patient

Secondary Survey
a/r Orbita dextra & sinistra : swelling (+), oedem (+)
a/r Zygoma dextra & sinistra :
L : swelling (+), oedem (+)
F : crepitation (+)
a/r dentoalveolar maxilla : crepitation (+), maloclution (+)
a/r mandibula : crepitation (+), maloclution (+)
a/r cruris sinistra :
L : swelling (+)
F : pain
M: ROM limited due to pain, good hemovascular , sat. 99%
a/r temporal sinistra : Hematom (+), crepitation (-)

List of patient

Clinical picture

List of patient

Localized Picture

List of patient

Localized Picture

List of patient

Laboratory Findings

Hb: 8,9
WBC : 17,9
RBC : 3,16
Hematocrite : 27,1
Plt : 141
PT/APTT : 13,2/22,3
INR : 1,15
BSN : 145
SGOT/SGPT: 117/80
Ur/Cr: 25/0,7

Na: 139,9
K : 3,4
Cl : 104,4

List of patient

X-Ray

X-Ray

X-Ray

Head CT-Scan

List of patient

USG

USG

USG
There is no abnormality in intraabdomen organ

Working Diagnosis
Mild head injury (GCS E3V5M6) + zygoma dextra fracture +
zygomaxilla sinistra fracture + dentoalveolar maxilla fracture
+ dentoalveolar mandibula fracture + susp. infra cochlear
tibia fracture.

List of patient

Management
IVFD Nacl 0,9% 20tpm
Head up 300
O2 NRM 10lpm
Blood Check
X-ray:cruris sinistra
CT Scan
Analgesic
Antibiotic
H2 Blocker
Rehecting a/r supra orbita
sinistra & mandibula

Consulted to Neuro surgeon:

Hospitalized
Observation of elevated
intracranial pressure
symptoms
Consulted to Plastic
surgeon
Consulted to Plastic surgeon :
Betadine gargle 3t/day
Gentamicin zalf
Liquid diet
Pro orif elective

List of patient

3. Mr. Muhamad Nur/ 29 yo/ July 1th, 2014 at 02.10 a.m

Chief complain: Lower Right Abdominal Pain

History :
10 hours before admission, patient complained about
pain that came suddenly. Pain, at first, was felt at
epigastric area and then spreading to lower right
abdominal area. Patient had history of fever, nauseous
(+), vomit (+). Patient then came to Ulin General hospital
further treatment.

List of patient

General Status
Compos mentis
Vital sign
BP : 140/90 mmHg
HR : 78 t/m
RR : 20 t/m
T : 37,8 C

List of patient

Physical Examination
Head/Neck

List of patient

Localized status
a/r abdomen :
pain (+) at right lower abdominal area,
Tenderness (+) at mc burney area

Digital Rectal Examination

Look

List of patient

List of patient

List of patient

Chest X-Ray

Laboratory Findings

Hb: 14,3
WBC : 13,9
RBC : 4,72
Hematocrite : 41,3
Plt : 202
Gran%: 86,1
Limfosit% : 8,2
MID% : 5,7
Gran# : 12,00

Limfosit# : 1,1
MID#: 0,8

List of patient

Working Diagnosis
Acute Appendicitis

List of
patient

Management

Blood Check
Thorax X-Ray
IV Line
Analgesic
H2blocker
Fasting
USG Appendix

Consulted digestive surgeon:

Pro appendectomy
List of patient

Thank You