Emergency Report February 26th-27th, 2014

Resident on duty: Dr. Ferdy

Chief on duty: Desy

Team: Okta, Farid, Joyce, Yasmin, Andita, Desita, Rani, Diah, Herdiko, Aditya, Ichwan

PATIENT LIST
Minor surgery Oncology surgery Digestive surgery Thorax cardiovascular surgery Plastic surgery Urology surgery Neurosurgery Pediatric surgery Orthopedic Total : : :1 :1 :::::1 : 3

Patients List
No Identity Admission to E.R. Diagnosis Management

1. Mr. john lombo/ 56 y.o.

February 26th, 2014 at 18.20

2. Mr. Rahmadian nor/ 16 yo

February 26th, 2014 at 20.55

Fatty liver IV Line Multiple Cholelitiasis Ketorolac 2x1 amp BPH Ranitidine 2x1 amp Consult digestive surgery Consult Internest Planning Explorasi CBD Consult Urology Surgery Harnal (1-0-1) Open fracture at IV Line dextra tibia middle TT- ATS 3rd oblique displaced Analgetic gustillo grade II Antibotic Closed fracture at H-2 blocker dextra fibula Wound toilet and suture proximal 3rd oblique Immobilization with posterior slap R/ oriff ps tibia

No

Identity

Admission to E.R.

Diagnosis

Management

3. Mr. Syamsuri/ 67 yo

February 14th, 2014 at 22.30

Abdominal pain e.c Susp inpenden ruptured aneurisma aorta + kidney stone (9mm) + Anemia + CKD + ISK

IV Line Co. Digestive Surgery NGT DC Resusitation fuild Tommorow will be see by digestive surgery Co. Urologi surgery Solve aneurisma first

1. Mr. John Lombo/ 56 yo/ February 26th 2014 at 18.20

Chief complain: Vomit History : 2 weeks ago the patien complaints that vomit, the contain of vomit is food. Patient complants too the pain in abdomen in region upper right and more pain if ate the colesterol food. The pain cant localizier. And then patient get a drugs from GP but the complaint not dissapear. 5 days after that patien did medical checkup and the diagnosis theres stone in gall baladder and fatty liver. patient hospitalized at Ansari Saleh in 1 week and revere to Ulin hospital. history of alchohol (-), often ate colesterol food (+), Feses not colored (-) urine like tea (+), fever (+), bloating (+) micturation normal.

Primary Survey
A Clear, gurgling (-), snoring (-)

Clear, RR=22 bpm, symmetric respiratory movement, symmetric VBS BP : 120/90 mmHg Pulse rate : 88 bpm, reguler, strong lifted, CRT < 2 sec. GCS E4V5M6, round and symmetric pupils diameter (3mm/3m), light reflexes (+/+), no paralysis

Secondary Survey
Eye : Anemic conjunctivae (-/-), icteric sclera (+/+) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-) I : Symmetric respiratory movement, lesion (-) P : Symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Head/Neck

Chest

Abdomen
Extremities

I : lesion (-), distension (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Warm peripher (+), edema (-) parese ( - / - ), other see status localis, swelling (-)

Status Urology
CVA Inspeksi : jejas (-/-), hematoma (-/-) Palpasi : massa teraba (-/-), nyeri tekan (-/-) Perkusi : nyeri ketok ginjal (-/-)

Flank Area
Inspeksi : massa (-/-), hematoma (-/-), jejas (-/-) Palpasi : massa tidak teraba, nyeri tekan (-/-)

Suprapubik
Inspeksi : buli tidak menonjol, jejas (-), hematoma (-), massa (-) Palpasi : nyeri tekan (-)

Genitalia OUE : bloody charge (-), edema (-), kateter (-).

Clinical Picture

Local Status
Rectal Touch Location : Upper Right prostate palpable Abdomen regio enlarged Murphy sign (-) Flat sulcus medianus Hepar found enlarged 5 fingers from arcs costae upper pole palpable and 3 fingers from proc. nodul (-) Xhipoideus, flat, nodul (-) tenderness (-) tenderness (-)

Laboratory findings
HB : 12 WBC: 22,9 RBC: 5,41 HT: 49 PLT: 212 PT/APTT: 10,1/22,3 LDH : 2142 SGOT/SGPT: 361/621 Albumin: 3,9 Bil tot/dir/indir : 5,9/4,4/1,5 Na+/K+/Cl-: 139/4,4/102,2

X-Ray

Working Diagnosis
Fatty liver Multiple cholelitiasis BPH

Management
IV Line Ketorolac 2x1 amp Ranitidine 2x1 amp Consult digestive surgery Consult Internest Planning Explorasi CBD Consult Urology Surgery Harnal (1-0-1)

2. Mr. Rahmadian Noor/ 16 yo/ February 26th 2014 at 20.55

Chief complain: wound and pain in right leg History : 1 hours before admission patient was riding a motorcycle and then hit by motorcycle from right side. Patient was fallen. The mechanisme of this accident is unknown. Unconsiousness (-), vomit (-), ear bleeding (-), nose/mouth bleeding (-/-/-),

Primary Survey
A Clear, snoring(-), gargling (-)

Clear, RR=24 bpm, symmetric respiratory movement, symmetric VBS BP : 120/80 mmHg Pulse rate : 96 bpm, reguler, strong lifted, CRT < 2 sec. GCS E4V5M6 round and symmetric pupils diameter (3mm/3mm), light reflexes (+/+)

A M P

7 hour before addmision

L
E

On the road

Secondary Survey
Head/Neck
Eye : Anemic conjunctivae (-/-), icteric sclera (-/-) other see status localis Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-) I : Symmetric respiratory movement, lesion (-) P : Symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Chest

Abdomen
Extremities

I : lesion (-), distension (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Warm peripher (+), edema (-) parese (-/-), swelling (-)

Clinical Picture

Local Status
Right Leg L:deformity (+) wound (+) 2x x cm,based on bone, irregular edge hematome (+), swelling (+) P: tenderness (+), distal neurovaskular. M: room ankle and knee normal (passively)

X-Ray
Bone discontinuity at right tibia middle 3rd oblique displaced. Bone discontinuity at right fibulla proximal 3rd oblique displaced.

Laboratory Finding
Hb 13,3 g/dl Leu 15,8 ribu/ul Erit 4,7 juta/ul Ht 38,4 vol% Tromb 196 ribu/ul GDS 141mg/dl SGOT/PT / 33 / 16 Na/K/Cl 140,6 / 4,2/ 101,2 Ureum /Creatinin : 31/ 0,8 PT/ APTT: 10 / 25

Working Diagnose
Open fracture at dextra tibia middle 3rd oblique displaced gustillo grade II Closed fracture at dextra fibula proximal 3rd oblique

Management
IV Line TT- ATS Analgetic Antibotic H-2 blocker Wound toilet and suture Immobilization with posterior slap R/ oriff ps tibia

3. Mr Samsuri/ 64 yo/ February 26th 2014 at 21.30

Chief complain: Abdominal pain and mass around umbilikal History : alloanamnesis 2 days ago, the pain felt in morning day and felt more pain at afternoon. And then patient scream because the pain. History like this ever felt 1 year ago but the pain can be relief with drugs their family bought in drugstore. complaints about around mass is unknown when the mass felt. history : weight loss (-), black feses unknown, hipertension (+), stroke (+) with complaints lip deviation about 2 years ago, trauma unkown. his job is farmer, smoking (-), Micturation (-).

Primary Survey
A Clear, gurgling (-), snoring (-)

Clear, RR=26 bpm, symmetric respiratory movement, symmetric VBS BP : 90/70 mmHg Pulse rate : 80 bpm, reguler, weakness lifted, CRT < 2 sec. GCS E3V5M3, round and symmetric pupils diameter (3mm/3m), light reflexes (+/+), no paralysis

Secondary Survey
Head/Neck
Eye : Anemic conjunctivae (-/-), icteric sclera (-/-) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)
I : Symmetric respiratory movement, lesion (-) P : Symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Chest

Abdomen
Extremities

I : lesion (-), distension (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Warm peripher (+), edema (-) parese ( - / - ), other see status localis, swelling (+)

Status Urology
CVA Inspeksi : jejas (-/-), hematoma (-/-) Palpasi : massa teraba (-/-), nyeri tekan (-/-) Perkusi : nyeri ketok ginjal (-/-)

Flank Area
Inspeksi : massa (-/-), hematoma (-/-), jejas (-/-) Palpasi : massa tidak teraba, nyeri tekan (-/-)

Suprapubik
Inspeksi : buli tidak menonjol, jejas (-), hematoma (-), massa (-) Palpasi : nyeri tekan (-)

Genitalia OUE : bloody charge (-), edema (-), kateter (-).

Clinical Picture

Local Status
Regio Periumbilical Insp : mass (+) venectation (-) ulcerasi (-) palp : soft (+) ireguller edge (+) pulatation (+) Thrill (-) Immobile (+) Aus : Bruit (-)

Rectal Touch prostate not enlarged Ampula recti not colaps sfingter ani strong blood (-) Feses (+) mass (-)

USG
Defect in abdominal aorta with an echoic lession (subumbilical regio) with size 64mm x 78mm x 67mm. Left Nefrolithiasis

Laboratory findings
HB : 9,7 WBC: 15,7 RBC: 4,28 HT: 35,9 PLT: 227 PT/APTT: 10,5/22,0 GDS: 107 SGOT/SGPT: 46/26 Albumin: 3,1 Ur/Cr: 190/4,2 Na+/K+/Cl-: 135,9/4,7/100,5

Urinalisa Color : cloudy yellow BJ 1.015 pH : 6.5 Keton : Negatif Glukosa : Negatif Billirubin : Negatif Blood smear : Negatif Nitrit : Negatif Urobilinogen : 0.2 Leukosit : Negatif

Urinalisa (sedimen) : Leukosit Eritrosit Silinder Epitel Bakteri Kristal

: Full : Full : Negatif : 1+ : +2 : Negatif

Working Diagnosis
Abdominal pain e.c Susp inpenden ruptured aneurisma aorta + kidney stone (9mm) + Anemia + CKD + ISK

Management
IV Line Co. Digestive Surgery NGT DC Resusitation fuild Tommorow will be see by digestive surgery Co. Urologi surgery Solve aneurisma first