Emergency Case Report

2014, Dec 2nd 3rd

Resident on Duty : dr. Yan Aditya

Chief Co-Assistant : Ady Adha Norsanie
Team :
Endah, Firdha, Bimo, Erina, Dyah, Mira

Minor Surgery

Digestive Surgery

:-

Thorax Cardiovascular Surgery

:-

Plastic Surgery

:-

Urology Surgery

:1

Neurosurgery

:1

Pediatric Surgery

:-

Oncology Surgery

:-

Orthopaedy

:1

Total

:3

No

Identity

Admission
to E.R.

Diagnosis

Treatment / Planning

1.

Traumatic Amputation Observation Vital Sign

Mr. Abdul
2014, 2nd
Karim/ 35 yo/ December / Digiti III Phalang Distal IVFD RL 20 gtm
Manus Dextra
1.13.04.02
03.00 p.m
Antibiotic
Analgesic
H2 blocker
Anti Tetanus Serum
Patient discard by request

2.

By. Azka Tri

Dalaksana/
43 d.o/
1.13.04.11

2014, 2nd SAH et parieto ocipital Observasi Vital Sign

December/ + ICH et frontal sinistra O2 2 lpm
ec APCD
8.20 p.m
IVFD D51/4NS 20 tpm mikro
Antibiotic
Manitol
Phenobarbital puyer 2x10gr
Consult to neurosurgery
Pro craniotomy evacuation

No

Identity

3.

Tn. Jarkani/
49 y.o/
1.13.04.23

Admission
to E.R.

Diagnosis

Treatment / Planning

Ruptur uretra + gross

2014, 3rd
December / hematuria e.c susp. Ca
buli
00.30 a.m

Obs. Vital Sign

Completely blood count
IVFD RL 2000cc/day
Antibiotic
H2 blocker
Analgesic
Co. Urology Surgery : Suprapubic Punction, USG Urologi,
Uretrografi & BVUC

Mr. Abdul Karim / 35 y.o / 1.13.04.02

2014, 2nd December / 03.00 p.m
Chief Complain : Open wound right hand

History :

3 hours before admission to the hospital, when he was working,

suddenly he got accident and his middle finger of right hand cut off by
wheel machine. The accident make his the top of middle finger lose on
by machine. History of unconsciousness (-). And then, his friend bring
him to the AURI general hospital,he got first aids thorax x-ray and get
analgesic in there. After that he referred to Ulin Hospital for further
treatment.

Primary Survey
A

Clear, snoring (-), gurgling (-)

Clear, RR= 20 bpm, symmetric respiratory

movement, symmetric VBS

BP : 160/100 mmHg
Pulse rate : 82 bpm, reguler, strong lifted,
CRT < 2 sec.

GCS E4V5M6, round and equal pupils

diameter (3mm/3m), light reflexes (+/+), no
paralysis

Analgesic

Hipertension

4 hours before
admission

Workplace

Secondary survey
Eye : Anemic conj. (-/-), icteric sclera (-/-), periorbita; hematoma
(-/-)
Mouth : Moist mucous membrane
Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/)

Head/Neck

Chest

Abdomen
Extremities

I : Symmetric respiratory movement, retraction (-)

P : Symmetric VF
P : Sonor in all lung field
A : Symmetric VBS, Rh (-/-), Wh (-/-)

I : Wound (-), distension (-), hematoma (-)

A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).
P : Tympanic in all quadrants
Wound (+) Digiti III Phalang Distal Manus Dextra
edema (-), paralysis (-)

Clinical Picture Local Status

a/r digiti III phalang distal manus

dextra,
Look : open wound (+) bone exposed
Feel: crepitation (-),
Movement: ROM normal limit

Manus AP/Lat/Obq Dextra

2014, 2nd December

Working Diagnose
Traumatic Amputation Digiti III Phalang Distal Manus Dextra

MANAGEMENT

Observation Vital Sign

IFVD RL 20 gtm
Antibiotic
Analgesic
H2 blocker
Anti Tetanus Serum

Consult to orthopaedy :
- Pro stumb plasty
- Patient discharge by request

An. Azka Tri Dalaksana/ 43 d.o/ 1.13.04.11

2014, 2nd December / 08.20 p.m
Chief Complain : Seizure
History :

3 days before admission to the hospital, mother complain about her child
(patient) get seizure. Seizure comes 2 times and the duration of each seizzure
is more than 5 minutes. History of fever (-). History of trauma (-). Hystory of
bleeding from mouth and intestine (-) Mother than brought her child to doris
silvanus hosp and hospitalized and got CT scan exam. Because from CT there
is intracranium bleeding patient reffered to Ulin General Hospital for further
treatment.
Born history : delivery by midwife, not cry spontanly, history inj vit. K (-), breast
milk (+), formula (-).
Pregnancys mother history : sick during pregnancy (-). Drug history (-).

Physical Examination
GCS E4V5M5

Vital sign :
BP = HR = 142 bpm
RR = 40 tpm
T = 36.7 C

Physical Examination
Head/Neck

Chest

Abdomen

Extremities

Eyes : No anemic conjunctiva, icteric sclera (-),

Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

I : Symmetric respiratory movement, no retraction

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

I : Inguinal lymph nodes enlargment (-)

A : Bowel sound (-)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-), distension (-) P : Tymphani

Warm, no oedema, no parese

Clinical Picture Local Status

CT HEAD
2014, 1ST December

LABORATORY
Hb 11.5 g/dl
Leucocyte 10700/l
Hematocrit 34.7 vol%
Trombocyte 531.000/ l
PT/aPTT 0.86/1.06 s
Glucose 110 mg/dl
SGOT/SGPT 51/37 U/I

Working Diagnosis
SAH et parieto ocipital + ICH et frontal sinistra
e/c APCD

Management

Obs. Vital Sign

Oxygen 2 lpm
IVFD D51/4NS 20 tpm mikro
Antibiotik
Manitol
Barbiturat/anti konvulsi
Consult to neurosurgery
Pro cito craniotomy evacuation

Mr. Jarkani/ 49 y.o/ 1.13.04.23

2014, 3nd December / 07.00 p.m
Chief Complain : not able to urinate

History :

Ten hours before admission to the hospital. Patient complained His urine
didnt out from folley cateter. history of stone urinate (-) history From
cateter we found reddish fluid hystory of red colour urinating occurred
since 1 month ago. And from 1 week ago he was not able to urinated
and got cathetered.
Patient go to PKM and there his catheterd was replaced his urin still
didnt out. Patient then refered to ULIN.
History of smoking (+) for 20 years
History of loose body weight (-)

Physical Examination
Conciousness :Compos Mentis
Vital sign :
BP = 180/120 mmHg
HR = 84 bpm
RR = 20 tpm
T = 36.8 C

Physical Examination
Head/Neck

Chest

Abdomen

Extremities

Eyes : No anemic conjunctiva, icteric sclera (-),

Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

I : Symmetric respiratory movement, no retraction

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

I : Inguinal lymph nodes enlargment (-)

A : Bowel sound (-)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-), distension (+)

Warm, no oedema, no parese

Clinical Picture Local Status

LABORATORY
Hb 13.7 g/dl
Leucocyte 16300/l
Hematocrit 40.5vol%
Trombocyte 400000/ l
PT/aPTT 0.77/0.96 s

Working Diagnosis
Ruptur uretra + gross hematuria e.c susp. Ca buli

Management

Obs. Vital Sign

Completely blood count
IVFD RL 2000cc/day
Antibiotic
H2 blocker
Analgesic
Co. Urology Surgery : Supra-pubic Punction, USG Urologi,
Uretrografi