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Emergency Report 3-4 Februari 2017
Emergency Report 3-4 Februari 2017
Coass on duty
Ahmad, Tommy, Fachrul,
Adli, Nandita, Elma, Risa,
Mutia, Ellsa, Shana
General Surgery : 2
Digestive Surgery : 1
Plastic Surgery : -
Urology Surgery : 2
Neuro Surgery : 1
Pediatric Surgery : -
Oncology Surgery : 1
Orthopaedy : 1
Total : 8
Patient List
No Identity Admission to ER Diagnose Treatment
Co to oncology surgery:
Education, Information,
Consultation to Patients
family about patients
condition now
Observation VS and urine
output on Emergency Unit
Co to orthopaedi:
Pro debridement + repair nail
bed + primary sutura
Patient List
No Identity Admission to ER Diagnose Treatment
Co to digestive surgery:
Outpatient clinic
Patient List
No Identity Admission to ER Diagnose Treatment
7 Ch. Maulana/5 February 4th Vulnus ictum e.c Extraction corpus alienum
y.o 00.20 corpus alienum et Wound care
regio dorsum Antibiotik
pedis dextra Analgetic
ATS
Patient List
No Identity Admission to ER Diagnose Treatment
Chief Complain:
Hard to breath
History of Current Disease:
Patient bought with her family because she has complain hard to
breath since 8 hours before admission. Hard to breath appear slowly
and became hardly. The complain decrease slightly if the patient sit
down. The patients breath look faster than usual. Patient not has
complain about chest pain. Now patient have fever too. The hard of
breath appear after she has complain of nausea and vomiting since 1
days before admission. The content of vomite is pouridge and drink
that she consumtion. The vomiting is about 5 times. There is no blood
and slime. Patient cannot defecate since one weeks before admission.
Since 2 weeks before admission patient just rest at bed because she
felt numb from waist to leg and has back pain. History of Trauma at
back and spine (-) History of stroke (-).
History of past illness
November, 2010: Patient has complain about mass at right breast
size like marble, solid, and there is not pain
February, 2011: The mass grew bigger like chickens egg and then
patients got biopsy procedure at Islams Hospital and diagnose with
Ca mamae stage IIIb and patient suggest to mastectomy but family
denial.
November, 2012: Patient has got Modified Radical Mastectomy by
general surgeon at Ansari Saleh Hospital and the result of biopsy is
Carsinoma ductal invasive grade III with Lymph node metastase and
then patient got chemotherapy six times.
March, 2015: Patient have complain there is new mass from old
scars of last operation size like nut, the colour is red, pain (-) and
then got operation by Oncology surgery with Biopsy procedure and
the result is invasive ca mamae residive. Patient suggest to got
radiotherapy but the device is error until now.
Vital Sign
BP: 90/50 mmHg
Temp: 38,1 celcius degree
RR: 37 times/minutes, fast and deep with abdominal
breath
HR: 94 beat/minutes, weak and hard to palpable
SpO2: 96% with NRM 10 LPM
Karnofsky Score: 40
Physical
Examination
Head : simetric, normocephal, mass (-), scar (-)
Eye : Anaemic conj. (-/-), icteric sclera (-/-), edem palpebra (-/-),
Head brill haematoma (-/-)
Mouth : Moist mucous membrane (-)
Neck : Increasion level of JVP (-) lacerated (-)
General State
I : symmetric respiratory movement, scars post mastectomy
(+)
Chest P : decrease of fremitus vocal at lower lung fields
P : Sonor
A : symmetric, rhonchi at all regio of lung, no wheezing
Neurologis state:
Ligth Reflex: DLR/IDLR (+/+)
Motoric : +5 +5 clonus: -/-
1 1
Sensoric: aestesia at T5 dermatom
Physiological: BPR +2 +2 APR +2 +2
TPR +2 +2 KPR +1 +1
Local State
Neurologis state:
Phatological Reflex
Babinski: -/+ Gordon: -/-
Chaddok: -/- Hoffman: -/-
Openheim: -/- Tromner: -/-
Scuffner: -/-
Ganda: -/-
Meningial Reflex
Neck stiffness: (-) Brudzinski I: (-)
Lasque: (-) Brudzinski II: (-)
Kerniq: (-)
Clinical Picture
Laboratory, January, 31th 2017
Examination Result Normal value
hemoglobin 13.3 11.00-16.70 g/dl
leucocyte 13.0 4.0-10.5 103 /ul
erythrocyte 4,44 4.50-6.00 106 /ul
hematocrit 40,9 42.00-52.00 Vol%
thrombocyte 175 150-450 103 /ul
Random Blood 266 <200 Mg/dL
Glucose
SGOT 170 0-46 U/I
SGPT 181 0-45 U/I
Urea 79 10-50 Mg/dL
Creatinine 1.7 0.7-1.4 Mg/dL
Working Diagnosis
Co to oncology surgery:
Education, Information, Consultation to Patients family about
patients condition now
Observation VS and urine output on Emergency Unit
Chief Complain :
Pain urination
History of Current Disease:
Since 2 months before admission, appears slowly, the pain felt
when the patient starting to urinate, the pain felt on the tip of penis.
The patient also complain poor stream. Blood (-) Pain on the waist (-)
incomplete voiding (-).
The pain was getting worse 12 hours before admission and the patient
cant urinate at all, then the patien brought to RS Anshari Saleh, and
got treatment antibiotic, analgetic and suggested to do circumcission,
but aborted, then revert to RS Ulin.
Vital Sign
GCS E3V2M5
HR : 79x/m
RR : 20x/m
T : 36,6 0C
Sp O2 99%
Physical
Examination
Head : simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-), Haematom (-/-), pupil
Head isokor (+/+)
Mouth : Moist mucous membrane, blood (-)
General State
Neck :mass(-)
I : distension (-)
A : Bowel sound decline
Abdomen P : defence muscular (-) tenderness (-) mass (-)
P : Tymphani (+)
Observation
Chief Complain:
Wound
History of Current Disease:
since 30 minutes before admission, wounded by the gear of
motorcycle machine and injured middle finger on right hand,
nail loss (+) bleeding (+), the finger still can moved and felt
the sensation.
Vital sign
GCS E1V1M4
BP : 120/90 mmHg
HR : 90 x/m
RR : 19 x/m
T : 36.5 0C
SpO2 : 99% with O2
Physical Examination
Head :simetric, normocephal
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head Mouth : Moist mucous membrane
Neck :Increasion level of JVP (-)
I : distension (-)
A : Bowel sound normal
Abdomen P : defence muscular (-)
P : Tymphani
Consult to orthopaedy
Pro debridement + repair nail bed + primary
sutura
4. Mr. Suhaedi/ 41 y.o
Chief Complain :
Bloodish urinate
History of Current Disease:
since 2 days before admission after patient got cystostomy
procedure and the blood found at catether tube. Since 1 month ago
before admission the patient complain about sandy urinate (white
like crystal) Pain felt when the patient started to urinate and
sometime patient must strain and incomplete voiding (+), poor
stream (+). But the bloodish urinate is not found yet. History of
trauma at abdomen, waist, and genitalia (-)
I : distension (-)
A : Bowel sound normal
Abdomen P : defence muscular (-) tenderness (+) at regio suprapubic, mass (-), ascites (-)
P : tympani
IVFD RL 20 tpm
Antibiotic
Co to urology surgery:
Hospitalized
USG Urology
Bipolar voiding urethrocystography
5. Mr. Alfiannoor/31 y.o
Chief Complain:
pain in anus
History of Current Disease:
since 10 days before admission, patient felt pain after defecated
and then pain felt continuesly. The first symptom appears was
bloodish feses, every single time the patient defecated. His feses
shape like goats feses. after that, patient came to central of
public health, and then patient reffered to Boejasin hospital at
tanah laut. patient hospitalized for 6 days but there was no good
outcome. Patient reffered to ulin hospital for futher modality of
diagnose and treatment.
urinate was normal, there is no nausea and vomit, abdominal
pain (-)
Vital Sign
Chief Complain:
bites wound
History of Current Disease:
Patient has wound caused by snake bites since 1 days before
admission. 10 hour before admission, patient felt nausea
vomiting. Patient vomit 2 times and contain food and water has
been eated. There is no blood and slime in the vomit contain. 8
hour before admission, patient felt numb at her right foot to
knee. There is no fever.
Clinical Picture
Localize state
Vulnus
Morsum at
regio pedis
dextra
Working Diagnosed
Chief Complain:
Pain at right foot
History of Current Disease:
The patient complain felt pain at right foot since 7 hours before
admission. Patients right foot sink in the yard home. After that,
patient punctured with wood chips. Fever (-), blood (-), pus (-).
Vital Sign
GCS: E4V5M6
BP: 110/70
HR: 98x/m
RR 22x/m
T 36,9
SpO2: 98%
Physical examination
Head :simetric, normocephal
Eye : Anaemic conj. (-/-), icteric sclera (-/-),
Head
General State
Mouth : Moist mucous membrane,
Neck :Increasion level of JVP (-)
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
Chest P : Sonor at all lung fields
A : symmetric VBS, no rhonchi , no wheezing
I : distension (-)
A : Bowel sound normal
Abdomen P : defence muscular (-) tenderness (-) mass (-), ascites (-)
P : tymphani
Chief Complain:
Decrease of consciousness
History of Current Disease:
The patient decrease of consciousness since 7.5 hour. The patient
falling on motorcycle when he try to dodged truck from different
direction. Helmet (-). History of unsciousness (-) seizure (-)
nausea/ vomitting (+/+) 2 times contain blood and food, nose, ear
mouth bleeding (+/-/+)
The family didnt know the mechanism of accident.
Primary survey:
A : clear, without c-spine control
B : Spontaneous, RR 20x/m, regular, Rh (-/-), Wh (-/-)
C : HR : 78 x/m, regular, strong, BP 100/70 mmHg
D : GCS 12: E3V4M5, pupil anisokhor, round 3mm/2mm, light
reflex +/+, Lateralization (-/-) , BH (-/-), BS (-/-), BR (-/+), BO (-/-)
Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 9 hours before accident
E = Environment on the street
Physical
Examination
Head : simetric, normocephal, mass (-), vulnus eskoriatum at regio frontalis sinistra 8x3cm
Face : vulnus eskoriatum at regio mandibula sinistra 5x8cm
Eye : Anaemic conj. (-/-), icteric sclera (-/-), edem palpebra (-/+), brill haematoma (-/-)
Head vulnus eskoriatum at regio rima orbita inferior sinistra 5x5cm
General State
Mouth : Moist mucous membrane, edema at labium superior(+)
Neck : Increasion level of JVP (-) lacerated (-)
5 5
TPR +2 +2 APR +2 +2