Emergency Report

February 8
th
-9
th
, 2014
Chief on duty:
Okta
Resident on duty:
Dr. Alexander
Team:
Rajihah, Dila, Bayu, Farid, Joyce, Yasmin, Desy
Minor surgery : -
Oncology surgery : -
Digestive surgery : 3
Thorax cardiovascular surgery : -
Plastic surgery : 1
Urology surgery : -
Neurosurgery :
Pediatric surgery : -
Orthopedic : 2
Total : 6
PATIENT LIST
Patients List
No Identity Admission to
E.R.
Diagnosis Management
1. Girl Silma
Lathifah/15
y.o
February
8
nd
, 2014
at 14.35

Constipation d.t
scibala with
hemorrhoid Gr.I
Laxative
Analgetic
H2 Blocker
Hemorrhoid drug
Discharge by permission
2 Boy Alex/
14 yo
February
8
nd
, 2014
at 18.00
Soft tissue
Swelling at right
cubiti
Analgetic IV
Rontgent Thorax and Cubiti

Co. Orthopedic
Oral Analgetic
Discharge by permission
3 Child Ida
Ariani/ 16
yo
February
8
nd
, 2014
at 18.00

Closed Fracture at
left ulna distal
third transvere
displace + close
fracture at left
tibial spine Meyer
Mc.Kiever II +
multiple
excoriation
IV Line
Analgetic
Antibiotic
H2 Blocker
Rontgen Thorac, pelvic , femur and
knee
Co. Orthopedic:
Posterior Slab
ORIF
No Identity Admission to
E.R.
Diagnosis Management
4 Mrs.
Herawati/
31 yo
February
8
th
2014,
at 18.20

Susp.Acute
Appendicitis
IV Line
H2 blocker
Laboratory check

Co. Digestive
Appendectomy emergency
5 Baby Nilna
Muna/ 10
months
February
8
th
2014,
at 19.10
Burn Injury at right
wrist, left tight, left
leg and left foot
Gr.IIA 3,5%
IV Line
Analgetic
Wound toilet

6 Mr.
Fahruzzaini/
54 yo
February
9th 2014
at 06.30
Diffuse
peritonitis d.t
susp. Gastric
perforation +
CKD gr. V
IV Line
Antibiotic
Analgetic
Laboratory check

Co. Digestive
Diuretic
Emergency Hemodialysis
Hospitalized in ICU post
hemodialysis
1. Girl Salma Lathifah/ 15 yo/ February 8th
2014 at 14.35
Chief complain: abdominal pain
History :
last 2 days, patient complaint abdominal pain at whole
abdomen. The pain was intermitent. Patient also complaint
constipation. The stool was hard and often with blood at the
end of defecation. Lump from anus (-)
General Status
Awareness: alert
GCS
15
: E
4
V
5
M
6


Vital sign
BP : 100/70 mmHg
HR : 72 t/m
RR : 20 t/m
T : 36,7
o
C
Physical Examination
Eyes : No anemic conjunctivae, icteric sclerae (-),
Nose : No epistaxis
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
Head/Neck
I : symmetric respiratory movement,
P : symmetric VF (+/+)
P : sonor at all lung
A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)
Chest
I : flat, distention (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,
rebound tenderness (-)
P : Tympani
Abdomen
Warm,, no parese, no edem
Extremities
Physical Examination
Local status :
Flat, supple, tenderness(-),
Rebound tenderness (-),
normal bowel sound

DRE
Look
Mass (-)
Abration (-)
Hemoroid (-)
Oedem (-)
Eritema (-)
Feel
Normal anal
sphincter
tone
Smooth
mucosa
Tenderness
in 3,7 and 11
hour
Handschoon
Feces (+)
Mucus (-)
Blood (-)

Laboratory Findings
Hemoglobin : 11,1
WBC : 7,5
RBC : 4,58
Hematocrit: 35,1
PLT: 375
Laboratory Findings
Urinalize
Color Cloudy Yellow
BJ : 1.010
pH: 6,5
Keton: -
Occult Blood: -
Urobilinogen: 0,2
Sediment
Leucosit 3-5
Erytrosit 0-1
Selinder -
Epithel +1
Bactery -
Crystal -

Clinical Picture
Working Diagnosis
Constipation d.t scibala with hemorrhoid gr. I
Management
Laxative
Analgetic
H2 Blocker
Hemorrhoid drug

Discharge by permission


2. Child Alex/ 15 yo/ February 8th 2014 at
18.00
Chief complain: Right elbow pain
History :
15 minutes before admission, patient was riding a
motorcycle. Helmet (-). And then crushed by other motorcycle
from right back. Unconsiousness (-), vomit (-), nose/ear/mouth
bleeding (-/-/-), seizure (-). His chin and chest was hit the road
and his right elbow folded.

Primary Survey
Clear, gurgling (-), snoring (-) A
Clear, RR=20 bpm, symmetric
respiratory movement, symmetric
VBS
B
BP : 120/70 mmHg
Pulse rate : 90 bpm, reguler, strong
lifted, CRT < 2 sec.
C
GCS E4V5M6, round and symmetric
pupils diameter (3mm/3m), light
reflexes (+/+), no paralysis
D
A
-
M
-
P
-
L
4 hours before
admission
E
On the road
Secondary Survey
Eye : Anemic conjunctivae (-/-), icteric sclera (-/-)
Mouth : Wet mucose
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, lesion (-)
P : Symmetric VF
P : Sonor in all lung field
A : symmetric VBS, Rh (-/-), Wh (-/-)
Chest
I : lesion (-), distension (-)
A : Normal bowel sound
P : H/L/M not palpable, tenderness (-), mass (-)
P : Tympanic in all quadrants
Abdomen
Warm peripher (+), edema (-) parese ( - / - ), other see status
localis, swelling (-)
Extremities
Clinical Picture
Local Status
Cubiti Dextra
L: Hematome (+), Swelling
(+), deformitas (-)
F: Tenderness (-),
crepitation (-), distal
sensibility (+)
M: ROM limited due to
pain
Chest X-Ray
Right Hand X-Ray
Working Diagnose
Soft Tissue Swelling at right cubiti
Management
Analgetic IV
Rontgent Thorax and Right Cubiti

Co. Orthopedic
Oral analgetic
Discharge by permission
3. Child Ida Ariani/ 16 yo/ February 8th 2014 at
18.00
Chief complain: Pain at left arm and left knee
History :
15 minutes before admission, patient was riding a
motorcycle. Helmet (-). And then crushed by other motorcycle.
Unconsiousness (-), vomit/nausea (-/-), nose/ear/mouth
bleeding (-/-/-), seizure (-). Patient complaint pain at left arm
and left knee.


Primary Survey
Clear, gurgling (-), snoring (-) A
Clear, RR=20 bpm, symmetric
respiratory movement, symmetric
VBS
B
BP : 120/80 mmHg
Pulse rate : 80 bpm, reguler, strong
lifted, CRT < 2 sec.
C
GCS E4V5M6, round and symmetric
pupils diameter (3mm/3m), light
reflexes (+/+), no paralysis
D
A
-
M
-
P
-
L
-
E
On the road
Secondary Survey
Eye : Anemic conjunctivae (-/-), icteric sclera (-/-) other see
status localis
Mouth : Wet mucose
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, lesion (-)
P : Symmetric VF
P : Sonor in all lung field
A : symmetric VBS, Rh (-/-), Wh (-/-)
Chest
I : lesion (-), distension (-)
A : Normal bowel sound
P : H/L/M not palpable, tenderness (-), mass (-)
P : Tympanic in all quadrants
Abdomen
Warm peripher (+), edema (-) parese ( - / - ),other see status
localis
Extremities
Clinical Picture
Local Status
Left wrist Region
L: swelling (+), deformitas
(+)
F: pain (+), crepitation (+)
M: ROM limited due to
pain
Local Status
Mentalis Region
L: Vulnus laceratum (+)
size 1x1 cm, bleeding (-)
F: pain (+), crepitation (-)
Local Status
Knee Region
L: Swelling(+)
hematome(-)
F: tenderness (+),
crepitation (-)
M: ROM Limited
Laboratory Findings
Hemoglobin: 11,0
WBC : 22,9
RBC: 4,14
Hematocrit: 32,7
PLT: 292
BSS: 144
SGOT/SGPT: 92/38
Ur/Cr: 36/1,0
Chest X-Ray
Left Forearm X-Ray
Pelvic X-Ray
Left Femur X-Ray
X-Ray
Left Knee Joint Left Ankle Joint
Working Diagnose
Closed Fracture at left ulna distal third transvere
displace + close fracture at left tibial spine
Meyer Mc.Kiever II + multiple excoriation

Management
IV Line
Analgetic
Antibiotic
H2 Blocker
Rontgen Thorac, pelvic , left femur and left knee

Co. Orthopedic
ORIF
4. Mrs. Herawati/ 31 yo/ February 8th 2014 at
18.20
Chief complain: Pain at right lower abdomen
History :
Since 1 days before admission, the patient felt pain at her right
lower abdomen continuously and more intense. Initially the
pain was felt at the epigastric region, and then it moved and
remained at the right lower abdomen. History of nausea (+),
vomiting (+), constipation since 4 days ago. Urinating within
normal limit.
General Status
Awareness: alert
GCS
15
: E
4
V
5
M
6


Vital sign
BP : 100/70 mmHg
HR : 76 t/m
RR : 18 t/m
T : 37,3
o
C
Physical Examination
Eyes : No anemic conjunctivae, icteric sclerae (-),
Nose : No epistaxis
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
Head/Neck
I : symmetric respiratory movement,
P : symmetric VF (+/+)
P : sonor at all lung field
A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)
Chest
I : flat, distention (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (+) ,
rebound tenderness (+)
P : Tympani
Abdomen
Warm,, no parese, no edem
Extremities
Physical Examination
Local status :
At abdominal region :
supple, distension (-),
bowel sound normal,
tenderness(+) at mc
burney point, rebound
tenderness (+), timpany
ALVARADO score : 8

Digital Rectal Examination
Look
Mass (-)
Abration (-)
Hemoroid (-
)
Oedem (-)
Eritema (-)
Feel
Normal anal
sphincter
tone
Smooth
mucosa
Tenderness
in 9 hour
Handschoon
Feces (+)
Mucus (-)
Blood (-)

Clinical Picture
Laboratory Findings
Haemoglobin: 11,6
WBC: 14,7
RBC: 4,00
Hematocrit: 34,6
PLT: 349
SGOT/SGPT: 22/19
Ur/Cr: 32/1,1

Laboratory Finding
Urinalize
Color Yellow
BJ : 1.020
pH: 6,5
Keton: +
Occult Blood: -
Urobilinogen: 0,2
Sediment
Leucosit 1-3
Erytrosit 1-3
Selinder -
Epithel +1
Bactery +2
Crystal -

Working Diagnose
Susp.Acute Appendicitis

Management
IV Line
H2 blocker
Laboratory check

Co. Digestive
Appendectomy emergency
5. Baby Nilna Muna/ 10 months/ February 8th
2014 at 19.10
Chief complain: Wound at left tight and leg
History :
30 minutes before admission, patient was spilled by hot
water at left tight and left leg. History of trauma (-)
General Status
Awareness: alert
GCS
15
: E
4
V
5
M
6


Vital sign
HR : 140 t/m
RR : 32 t/m
T : 36,7
o
C
Physical Examination
Eyes : No anemic conjunctivae, icteric sclerae (-),
Nose : No epistaxis
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
Head/Neck
I : symmetric respiratory movement,
P : symmetric VF (+/+)
P : sonor at all lung field
A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)
Chest
I : flat, distention (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,
rebound tenderness (+)
P : Tympani
Abdomen
Warm,, no parese, no edem
Extremities
Physical Examination
Local status :
At right wrist region :
Burn injury gr. IIA
0,5%

Physical Examination
Left Tight : burn injury
Gr. IIA 1,5 %
Left leg : burn injury
Gr. IIA 0,5%
Dorsum foot : burn
injury Gr.IIA 1%

Working Diagnose
Burn Injury at right wrist, left tight, left leg and
left foot Gr.IIA 3,5%
Management
IV Line
Analgetic
Wound toilet
6. Mr. Fahruzzaini/ 54 yo/ February 9th 2014 at
06.30
Chief complain: abdominal pain
History :
since 2 days before admission, patient complaint cant do
micturition. Patient also complaint abdominal pain and difficult
to defecation. Difficult to urinate, decrease stream (-), Bloody
urinate (-), sandy urinate (-), stone urinate (-). History of
consumption pain relievers for 1 year. Trauma (-).
General Status
Awareness: alert
GCS
15
: E
4
V
5
M
6


Vital sign
BP : 90/60 mmHg
HR : 140 t/m
RR : 32 t/m
T : 36,7
o
C
Physical Examination
Toxic face
Eyes : No anemic conjunctivae, icteric sclerae (-),
Nose : No epistaxis
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
Head/Neck
I : symmetric respiratory movement,
P : symmetric VF (+/+)
P : sonor at all lung field
A : symmetric VBS+/+, rhonchi (+/-), wheezing (-/-)
Chest
I : convex, distention (+)
A : decrease Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (+) ,
rebound tenderness (+)
P : Tympani
Abdomen
Warm,, no parese, no edem
Extremities
Physical Examination
Local status :
Convex, distention (+),
tenderness(+), Rebound
tenderness (+),
decrease bowel sound

Clinical Picture
DRE
Look
Mass (-)
Abration (-)
Hemoroid
(-)
Oedem (-)
Eritema (-)
Feel
Weak anal
sphincter
tone
Smooth
mucosa
Handschoon
Feces (+)
Mucus (-)
Blood (-)

Laboratory Findings
Haemoglobin: 12,1
WBC: 7,0
RBC: 4,11
Hematocrit: 34,9
PLT: 479
SGOT/SGPT: 55/24
Cr: 5,8

Abdomen X-Ray
Working Diagnose
Diffuse peritonitis d.t susp. Gastric perforation +
CKD gr. V

Management
IV Line
Antibiotic
Analgetic
Laboratory check

Co. Digestive
Diuretic
Emergency Hemodialysis
Hospitalized in ICU post hemodialysis