Académique Documents
Professionnel Documents
Culture Documents
Resident on duty:
dr. Alma Wijaya
Chief on duty:
Adit
Team:
Pras, Erika, Strata, Lucky, Nida, Vista
PATIENT LIST
Minor surgery
:2
Oncology surgery
Digestive surgery
Plastic surgery
Urology surgery
:3
Neurosurgery
:1
Pediatric surgery
Orthopedic
:1
Total
:7
Patients List
No
Identity
Admission to
E.R.
Diagnosis
Management
Mr. Fajar, 26
yo/
December
22nd, 2014
at 15.15
Patients List
No
2.
3.
Identity
Admission to
E.R.
Diagnosis
Mr. Rizkian
12 yo/
Lacerated wound
December
22nd 2014 at at right antebrachii
region
18.05
Mr. Arkasi 61
yo/
Management
Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker
Consult to digestive surgery:
Obsv. Vital sign
Co. Urology
Consult to urology:
Antibiotic
H2 Blocker
Analgetic
Pro uretrocystography
If cant urinate, DC cateter small
caliber (RF)
Join treatment with digestive
Patients List
No
Identity
Admission to
E.R.
Diagnosis
Vesico
4. Mr. Rusbani December Fistula
post
50 yo/
22nd 2014 Cutaneus
open
at 21.00
prostatectomy +
Anemia
+
Trombositopeni +
hypoalbunemia+
severe Sepsis
Management
Co Urology surgery:
Observation of Vital Sign
O2 6 lpm
IVFD Rl : D5 3:1 2000cc/day
Antibiotic
Analgetic
H2 Blocker
Blood Transfution 2 kolf
Albumin injection
Patients List
No
Identity
5. Mr. Samsul
Bahri 45
yo/
Admission to
E.R.
Diagnosis
6. Mr.
December
Open
Mulyana 55 22nd 2014 Post
Cystotomy
d.t
yo/
at 22.55
Susp
Stricture
Uretra Posterior
Management
IVFD RL
Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker
IV Line
Antibiotic
analgetic
H2 blocker
Co Urologist surgery:
Pro BVUC
Patients List
No
Identity
7. Mr. Samuel
Salodong
31 yo/
Admission to
E.R.
Diagnosis
Management
Consult to Ortopaedy
Posterior slab
Analgetic
H2 Blocker
Pro ORIF elective
Primary Survey
Secondary Survey
Head/Neck
Eyes : racoon eyes (+/+), anemic conjungtivae (+/+), icteric sclerae (-/-)
Nose : rhinohargia (+)
Ear : otohargia (+), battle sign (+)
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-), cephal
hematom (-)
Chest
Abdomen
Extremities
I : distention (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,
rebound tenderness (-)
P : Tympani
(-)
(-)
On the road
Localized Status
Localized Status
Localized Status
Localized Status
Localized Status
a/r antebrachii dextra:
L: edem (+), deformity
(+), angulation (+)
F: crepitation (+)
M: ROM limited
Localized Status
a/r Capitis:
L: racoon eyes (+),
otohargia (+), Rhinohargia
(+)
Hematom (-), batlle sign (-)
F: crepitation (-)
Femur X-ray
December, 22nd 2014
Antebrachii X-ray
December, 22nd
2014
LABORATORY FINDING
13,5Result
HEMATOLOGY
Parameter
Normal Value
Hemoglobin
10,6
14,0-18,0 g/dl
Lekosit
16,1
4,0-10,5 ribu/ul
Eritrosit
4,31
4,5-6,0 juta/ul
Hematokrit
31,4
42-52 vol %
Trombosit
151
150-450 ribu/ul
MCV
72,9
80-97 fl
MCH
24,5
27-32 pg
MCHC
33,7
32-38 %
Ureum
47
10-50 g/dL
Creatinin
1,3
0,7-1,4 mg/dL
GDP
SGOT/ SGPT
135
133/49
<200 mg/dL
0-45 U/I
23
PEMERIKSAAN
HASIL
RUJUKAN
PT
12,3
1,08
11,4
20,8
26,1
9,9-13,5 dtk
INR
Control Normal PT
APTT
Control Normal APTT
22,2-37 dtk
SATUAN
U/I
24
Working Diagnosis
Severe Head Injury GCS E2 Vx M5+ Cerebral
contusion + SAH+ Susp. Fracture Basis Cranii
Fossa Anterior Et Media + left Pulmonary
contusion+ Closed Fracture of right Femur
Midle 3rd Cominutive Displaced+ Closed
Fracture right Distal End Radius fryckman
type III
Management
Consult to neurology surgery:
- Obsv. Vital sign
- Head up 30 degree
- IVFD NS 2500cc/24 hours
- Antibiotic
- H2 Blocker
- Analgetic
- Hospitalized ICU
Consult to Cardio Thoracic Vascular surgery:
- X-ray Thorax serial/ 12 hours
- Conservative therapy
Consult to ortophaedic:
- Skin traction dextra
- Spalc for antebrachii
- Pro ORIF elective
2. Mr. RizkianSuri/
1250
yo/
December 22nd 2014 at
Yo/1-11-55-77
18.05
Chief Complain : Wounded hand
History :
an hours before admission, pts fell at his home while
carring a plate. The plate became broken and its
wounded his right arm. A lot of bleeding comes from
the wound. He wrap his wound with some of clothes.
Pts then brought to Ulin general hospital by his
family for further treatment.
Primary Survey
Rh -/-, wh -/-
Secondary Survey
Head/Neck
Chest
Abdomen
Extremities
(-)
(-)
(-)
At home
Clinical Pictures
Localized Status
a/r antebrachii:
L: edem (-), deformity (-), wound (+),
size diameter 5 cm, base wound fascia
(+)
F: tenderness (-), crepitation (-), pain
(+)
M: ROM Active
Post hecting
Working Diagnosis
Lacerated wound at right antebrachii region
Management
Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker
3. Mr. ArkasiSuri/
61 50
yo/
December 22nd 2014 at
Yo/1-11-55-77
18.40
Chief Complain : bump at scrotum
History :
since one year before admission, pts complaint that
there was a bump on his left scrotum. At the
begining, the bump could go back in and out. 10
days before admission the bump on his scrotum got
bigger and couldnt go in anymore. Defecate (+),
pain (+), urinate (+). Pts then seek treatment to
Amuntai hospital, he was operated but at durante
operation, hernia sach wasnt found. The operation
back then was imidiately stop. Pts then brought to Ulin
Hospital for further examination.
Physical Examination
Compos Mentis
BP: 130/100mmhg
P: 82 tpm
RR: 20 tpm
T: 36,6 C
CVA
Clinical Picture
Surgical wound +
Fibrosis at OUE
LABORATORY FINDING
13,5Result
HEMATOLOGY
Parameter
Normal Value
Hemoglobin
11,9
14,0-18,0 g/dl
Lekosit
11,7
4,0-10,5 ribu/ul
Eritrosit
4,26
4,5-6,0 juta/ul
Hematokrit
36,2
42-52 vol %
Trombosit
325
150-450 ribu/ul
MCV
85,1
80-97 fl
MCH
27,9
27-32 pg
MCHC
32,8
32-38 %
Ureum
30
10-50 g/dL
Creatinin
0,8
0,7-1,4 mg/dL
GDS
SGOT/ SGPT
272
43/48
<200 mg/dL
0-45 U/I
44
PEMERIKSAAN
HASIL
RUJUKAN
PT
12,8
1,11
11,4
27,6
26,1
9,9-13,5 dtk
INR
Control Normal PT
APTT
Control Normal APTT
22,2-37 dtk
SATUAN
U/I
45
X-ray Pelvic
X-ray Abdomen
USG
USG
Expertise
Right scrotum:
Seen bowel filling the right scrotum
Right testis looks unclear
Left scrotum:
Seen bowel filling the left scrotum
Left testis looks unclear
Incidental finding at right ingunal regio:
Seen Vesica urinaria at right inguinal dextra regio
Conclution:
Support the sign of hernia scrotalis bilateral
Working Diagnosis
Obsv. Scrotal Mass e.c susp Inguinal Bladder
Interna
Management
Consult to digestive surgery:
Obsv. Vital sign
Co. Urology
Consult to urology:
Antibiotic
H2 Blocker
Analgetic
Pro uretrocystography
If cant urinate, DC cateter small caliber (RF)
Join treatment with digestive
Physical Examination
Compos Mentis
BP: 130/90mmhg
P: 108 tpm
RR: 24 tpm
T: 36, C
CVA
Clinical picture
a/r abdomen
I:: Ascites, wound post op
is wet, pus (+),
A: P: Pain (+),
Urine (+)
Palpable pain (+) a/r
suprapubic
Release pain (-)
P: Shifting dullnes (+)
LABORATORY FINDING
13,5Result
HEMATOLOGY
Parameter
Normal Value
Hemoglobin
7.8
14,0-18,0 g/dl
Lekosit
1.3
4,0-10,5 ribu/ul
Eritrosit
2.85
4,5-6,0 juta/ul
Hematokrit
24.1
42-52 vol %
Trombosit
103
150-450 ribu/ul
MCV
84,6
80-97 fl
MCH
27,3
27-32 pg
MCHC
32,3
32-38 %
Ureum
151
10-50 g/dL
Creatinin
2.1
0,7-1,4 mg/dL
GDS
SGOT/ SGPT
161
28/19
<200 mg/dL
0-45 U/I
59
PEMERIKSAAN
HASIL
RUJUKAN
SATUAN
Albumin
2.6
3.5-5.5
g/dl
60
Working Diagnosis
Fistula
Vesico
Cutaneus
post
open
prostatectomy + Anemia + Trombositopeni +
hypoalbunemia+ severe Sepsis
Management
Co Urology surgery:
Observation of Vital Sign
O2 3-4 rpm
IVFD Rl : D5 3:1 2000cc/day
Antibiotic
Analgetic
H2 Blocker
Blood Transfution 2 kolf
Albumin injection
6. Mr. Samsul
Bahri
45 yo/ December 22nd
Suri/
50 Yo/1-11-55-77
2014 at 22.30
Chief Complain : Had an accident (?)
History :
an hours before admission, pts rode his motorcycle
with his wife. They were suddenly got crushed with
another motocycle from the back. He and his wife
fell to the ground. He wore a helmet, but still injury
his forehead. There were no history of bleeding from
ears, mouth and nose. Fainting (-), vomit (-). Pts then
brought to Ulin general hospital by his family for
further treatment.
Primary Survey
Rh -/-, wh -/-
Secondary Survey
Head/Neck
Chest
Abdomen
Extremities
(-)
(-)
(-)
On the Road
Clinical Pictures
Localized Status
a/r peri orbita dextra
L: edem (+), deformity (-), wound (+), size
diameter 2 cm, base wound bone (+), active
bleeding (-)
F: tenderness (+), crepitation (-), pain (+)
Localized Status
a/rfemur dextra
L: edem (+), deformity (-), wound (+),
size diameter 5 cm, base wound bone
(+)
F: tenderness (+), crepitation (-), pain
(+)
M: ROM limited due to pain
Post hecting
Skull X-ray
Thorax X-ray
Knee X-ray
Working Diagnosis
CKR + Vulnus laxceratum a/r periorbita dextra,
genu dextra
Management
IVFD RL
Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker
Physical Examination
Compos Mentis
BP: 130/90mmhg
P: 10 tpm
RR: 24 tpm
T: 36, C
CVA
LABORATORY FINDING
13,5Result
HEMATOLOGY
Parameter
Normal Value
Hemoglobin
12.1
14,0-18,0 g/dl
Lekosit
17300
4,0-10,5 ribu/ul
Eritrosit
4,76
4,5-6,0 juta/ul
Hematokrit
36
42-52 vol %
Trombosit
213
150-450 ribu/ul
Ureum
49
10-50 g/dL
Creatinin
0,7-1,4 mg/dL
GDS
SGOT/ SGPT
134
17/17
<200 mg/dL
0-45 U/I
Albumin
4.49
PT
4 minute
APTT
2 minute 10 second
80
PEMERIKSAAN
HASIL
RUJUKAN
PT
4
1,08
11,4
210
26,1
9,9-13,5 dtk
INR
Control Normal PT
APTT
Control Normal APTT
22,2-37 dtk
SATUAN
U/I
81
USG
Expertise
Conclusion:
1. Pelvicocaliectasis Ren Bilateral
2. Cystitis
3. Susp. Distal Ureter Calculy and diverticel at
left lateral vesikurinaria
4. Hyperplasia Prostat
Cystostomy bag
Working Diagnosis
Post Open Cystotomy ec Susp Strictur Uretra
Posterior
Management
IV Line
Antibiotic
analgetic
H2 blocker
Co Urologist surgery:
Pro BVUC
8. Mr. SamuelSuri/
Salodong
31 yo/ December 23rd
50 Yo/1-11-55-77
2014 at 02.15
Chief Complain : pain at right leg
History :
3 days before admission, pts fell from stair. He
dislocate his foot cause it used to support his body.
Pts complain pain and swelling at his leg. History of
fainting (-), bleeding at his ears, nose, and mouth (-)
Pts then brought to Ulin general hospital by his
family for further treatment.
Primary Survey
Rh -/-, wh -/-
Secondary Survey
Head/Neck
Chest
Abdomen
Extremities
(-)
(-)
(-)
Clinical Pictures
Localized Status
a/r cruris dextra et pedis dextra
L: edem (+), deformity (+), wound (-),
angulation (+)
F: tenderness (+), crepitation (+), pain (+)
M: ROM limited
Cruris X-ray
Pedis X-ray
Working Diagnosis
Closed fracture cruris 1/3 distal intra artikular
cominutive displaced dextra
Management
Consult to Ortopaedy
Posterior slab
Analgetic
H2 Blocker
Pro ORIF elective