Emergency Report

May 12th 13th 2016

Resident on duty:
dr. Shanti Fernandez

General Surgery

Digestive Surgery

Thorax Cardiovascular Surgery :

Plastic Surgery

Urology Surgery

Neuro Surgery

Pediatric Surgery

Total

:
:

1
:

Oncology Surgery
Orthopaedy

Patient List
No
1.

Identity
Ch. Aulia/
4y.o

Admission to
ER
May 12th
2016

Diagnose
Mild head injury +
open fracture right
depres frontalis +
skin loss + right
fracture rima orbita

Treatment

Observation Vital
sign
Head up 30 deg
Oxygen
IVFD NS
H2 blocker
analgetic
Antibiotic
Complate blood
count
Ct scan
Consult to plastic
surgery pro local
flap elective
Consult to neuro
surgery cito
debridement

Patient List
No

Identity

2.

Mr. Rabiansyah /
30 y.o

Admission to
ER

Diagnose

Treatment

May 12th 2016

Appendicitis acute

VS Obs
Analgetic
Antibiotic
H2 blocker
Complete blood
count
Complete urine
X-Ray
Consult to
digestive
surgery cito
appendictomy

Patient List
No

Identity

3.

Mr. Tamrin/
43y.o

Admission to
ER

Diagnose

May 12th 2016

Appendicitis acute

Treatment

VS Obs
Analgetic
Antibiotic
H2 blocker
Complete blood
count
X-ray
Consult digestive
surgery cito
appendictomy

1. ch. Aulia / 4 y.o

CC: headache
7hr before admission patient felt when she got a ride on a
motorcycle, and the right head heated the street. Helm (-),
vomit (-) bloody nose (-), bloody ear (-), bloody mouth (-),
patient brought to Datu Sanggul hospital for the first aid,
and then reverse to Ulin hospital for furder treatment.

Primary Survey
A

Clear, snoring (-), gurgling (-), cspine control (-)

Clear, RR= 24 bpm, symmetric
respiratory movement, symmetric
VBS
Pulse rate : 88 bpm, reguler, strong
lifted, CRT < 2 sec.
GCS E4V5M6, round and equal
pupils diameter (3mm/3mm), light
reflexes (+/+), no paralysis

3 hours before
admission
At the garage

Physical Examination
Head : Normocephali, open wound (-)
Eye : Anemic conj. (-/-), icteric sclera (-/-)
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

Head/Nec
k

Chest
Abdome
n
Extremities

I : symmetric respiratory movement

P : symmetric VF
P : Sonor both lung
A : symmetric VBS, Rh (-/-), Wh (-/-)

I : flat (-) laseration (-), distended (-)

A : Bowel sound (+) Normal
P : H/L/M not palpable, tenderness (-), rebound
tenderness (-), muscular rigidity (-)
P : tympani all region

Warm extremities, edema (-/-/-/-), wound (+) right

knee

Local Status
a/r right knee
L : open wound (+),
active bleeding (-)
F : base subkutis,
crepitation (-), Step
off (-), hematom (+),
lenght 5x1x0.5cm,
irregular edge
M : normal

Working Diagnosis :
Lacerated wound at right knee

Planning
Observation Vital
sign
Analgetic
Antibiotic
ATS-TT
Debridement
Primary Suture
Patient discharge by
permission

2. Mr. rabiansyah/ 30 y.o

Chief Complain:
pain at lower rightg abdomen
History of Current Disease:
Since 3 day before admission, he felt pain
at his abdomen. The pain was initially felt
at lower right abdomen, and no refered
pain to other abdomen region. He felt pain
continous and getting severe since 1day
before admisson . Nausea (+), vomiting
(+), anorexia (+), fever (+). The patient
didnt got any medication yet. He was

Primary survey :
A : Clear, without c-spine control
B : RR 22 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP:120/ 80 mmhg HR : 90x/m;
D : GCS E3V5M6, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 3 hours before accident
E = Environment at futsal arena

Secondary
survey Head
Head

:simetric, normocephal, brill haematom (-) batle

sign (-) , BO(-/-) BR(-)
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)

General Status

Chest

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi , no wheezing

Abdomen

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

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

Extremities

warm extremities, edema (-), parese (-)

Clinical picture

Laboratory
Examination

Result

Normal value

hemoglobin

12,3

11.00-16.00

g/dl

Leucosit

8,4

4.0-10.5

Thousand /ul

eritrosit

4,49

4.50-6.00

milion /ul

hematocrit

40,9

42.00-52.00

Vol%

trombocit

250

150-450

Thousand /ul

Random Blood
Glucose

100

<200

Mg/dL

SGOT

35

0-46

U/I

SGPT

17

0-45

U/I

Urea

28

10-50

Mg/dL

Creatinine

0,7

0.7-1.4

Mg/dL

Laboratory
Examination

Result

Normal value

PT

9,9

9.9-13,5

secon

APTT

23,5

22,2- 37

secon

INR

0,87

CT scan

Working Diagnosis
Mild head injury GCS 14
Cerebral contussion at right
temporal

Management
VS Obs
O2
Head up 30 deg
IVFD NS
Analgetic
Antibiotic
H2 blocker
Complete blood count
CT - Scan
Consult to Neurosurgery Hospitalized

3. Mr. Tamrin/ 43 y.o

Chief Complain :
Pain at lower right abdomen
Current History :
Since 3 day before admission, he felt pain at his
abdomen. The pain was initially felt at lower right
abdomen, no refered pain to other region. He felt
pain continous and getting severe since 2hr
before admisson . Nausea (+), vomiting (+),
anorexia (+), fever (+). The patient didnt got any
medication yet. He was brought to Ulin General
Hospital for further treatment.

Vital sign

BP 130/80 mmhg
Hr 78 Bpm
RR 20 tpm
T 38 0C

Phisic
Diagnostic
Head

Head
:simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Mouth : Moist mucous membrane,
Neck
:Increasion level of JVP (-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi , no wheezing

General Status

Chest

Abdomen

Extremities

I : distension (-) flat.

A : Bowel sound decrease
P : defance muscular (+) at lower right abdomen,
tenderness (+), rebound terderness (+)
P : dull (+)

warm extremities, edema (-), parese (-)

Clinical picture
DRE : normal sphyncter tone,
smooth mucosa, mass (-),
rectal vault wasnt collapse,
tenderness (+) at 9-15 oclock
Gloves : feces (+), blood (-)

Laboratory
Examination

Result

Normal value

hemoglobin

14.9

11.00-16.00

g/dl

Leucosit

21.7

4.0-10.5

Thousand /ul

eritrosit

5.09

4.50-6.00

milion /ul

hematocrit

44.6

42.00-52.00

Vol%

trombocit

308

150-450

Thousand /ul

Random Blood
Glucose

131

<200

Mg/dL

SGOT

26

0-46

U/I

SGPT

27

0-45

U/I

Urea

28

10-50

Mg/dL

Creatinine

1.2

0.7-1.4

Mg/dL

Laboratory
Examination

Result

Normal value

PT

11.2

9.9-13,5

secon

APTT

31.5

22,2- 37

secon

INR

0.98

X ray

USG abdomen (27-032016)

Working Diagnosis
Peritonitis difuse due to susp.
Apendicitis perforation

MANAGEMENT
VS Obs
IVFD RL
Antibiotic
Analgetic
H2 blocker
Complete blood count
X-Ray
Co to Digestive Surgery pro Laparotomy
exploration cito

Intra Operatif Finding

We found :
- Peritonium fluid mixed with pus 100 cc
- Appendix retrocaecally, 10cm cm in length, 1.5
cm in diameter, gangrenous, fecolith (+),
perforation at middle appendix
- Fibrin (+), pocket abscess (+)

4. Mr. Bahrudin / 42 y.o

Chief Complain:
Decrease of conciousness
History of Current Disease:
Since 6 hours before admission, patient got
accident at Anjir. He was riding motorcycle, helmet
(-), and hit another motorcylce from opposite
direction. The mechanism of trauma was unknown,
history of unconsciousness (+) history of vomiting
(+) 4 times. history of bleeding from ear nose and
mouth (-/-/-). then patient brought by civilian to
Kapuas hospital and refered to Ulin General
Hospital for further treatment

Primary survey :
A : Clear, without c-spine control
B : RR 22 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP:110/ 70 mmhg HR : 88x/m;
D : GCS 13 E3V4M6, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal 5 hours before accident
E = Environment on the street

Physical
diagnosis

General Status

Clinical picture
Maxilofacial status
At orbita : diplopia cannot evaluated
due to decrease conciousness and
edema right palpebrae
At right zygoma : Crepitation (+),
edema (+), step off defect (+)
At nasal : deformity (-), open wound (-),
crepitation (-), bone discontinuity (-)
At maxilla : deformity (-), open wound
(-), crepitation (-), bone discontinuity
(-), step of defect (-), floating
maxilla (-)
At left mandibula : deformity (-), open
wound (-), crepitation (-), bone
discontinuity (-), stable mandibula,
malocclusion cannot evaluated due
to decrease conciousness.

Laboratory
Examination

Result

Normal value

hemoglobin

12.8

11.00-16.00

g/dl

WBC

13.3

4.0-10.5

Thousand /ul

eritrosit

4,53

4.50-6.00

milion /ul

hematocrit

37.8

42.00-52.00

Vol%

Platelets

287

150-450

Thousand /ul

Random Blood
Glucose

93

<200

Mg/dL

SGOT

46

0-46

U/I

SGPT

32

0-45

U/I

Urea

39

10-50

Mg/dL

Creatinine

0.9

0.7-1.4

Mg/dL

Laboratory
Examination

Result

Normal value

PT

10.2

9.9-13,5

secon

APTT

23,8

22,2- 37

secon

INR

0,85

x-ray

CT Scan

Working Diagnosis
Moderate head injury GCS 13
EDH with diameter 5mm at right frontal
and Cerebral contussion at right frontal
Closed fracture of right zygoma

Management
VS Obs
O2
Head up 30 deg
IVFD NS
Analgetic
Antibiotic
H2 blocker
Complete blood count
CT - Scan
Consult to Neurosurgery Hospitalized
Consult to Plastic surgery hospitalized