Emergency Case Report

June 8th – 9th 2019

Resident On Duty
Oscar Tri Joko
Riz Sanfebrian Adiatma

The B Team
General Surgery : 2 Patients

Digestive Surgery : 2 Patients

Thorax Cardiovascular Surgery :-

Plastic Surgery :-

Urology Surgery : 1 Patient

Neuro Surgery :-

Pediatric Surgery :-

Oncology Surgery : 1 Patient

Orthopaedic : 1 Patient

Total : 7 Patients
 Patient List
No Identity Admission to ER Diagnosis Treatment

1. Mrs. Asnah/59yo/MR Admitted June 8th at Massa pelvic susp Treatment from ER
1427642 05.00 PM rhabdomiosarcoma • IVFD crystalloid
• Inj. analgetic
• Inj. H2 blocker

Consult to Digestive Surgery

• Hospitalized
• PRC transfusion until hb >10
 Patient List
No Identity Admission to ER Diagnosis Treatment

2. Mr. Muhammad Admitted June 8th Open fracture at right Treatment in ER

Taufik/20yo/MR 2019 at 06.00 PM patella chipping with • Debridement
1430135 partial rupture patellar • Primary suture
tendon. • Propylaxis tetanus
• Po antibiotic
• Po analgetic
• Patient out by permission
 Patient List
No Identity Admission to ER Diagnosis Treatment

3. Mrs. Mariati/61yo/MR Admitted June 8th Myeloradculopathy at level ER Treatment:

1430139 2019 at 07.32 PM T7 due to burst fracture at
vertebra T7 dan T9 due to
susp. Spondylytis tb dd/
metastase bone disease
• IVFD Crystalloid
• Inj. analgetic
• Inj. H2 blocker
Consult to Orthopaedic:
• Hospitalized
• Continue OAT
 Patient List
No Identity Admission to ER Diagnosis Treatment

4. Mrs. Mariana/52yo/MR admitted June 8th Malignant Neoplasma of Treatment from ER:
0630190 2019 at 09.00 PM the Breast sinistra + susp. • IVFD NS 20 tpm
Brain metastasis post MRM • Ro thorax
post Kemoterapi subtype
her 2 +3 Consult to oncology surgery:
• Hospitalized
• Ct scan kepala with contrast
• USG
• CEA/ Ca 15-3
 Patient List
No Identity Admission to ER Diagnosis Treatment

5. Mr. Badran/ 46 yo/ MR admitted June 8th Lacerated Wound at region Treatment in ER
1430149/ 2019 at 09.45 PM palpebra superior sinistra • Wound toilet
• Primary suture
• Tetanus Prophylaxis
• Po antibiotic
• Po analgetic
• Patient out by permission
 Patient List
No Identity Admission to ER Diagnosis Treatment

6. Mr. Birhan /49 yo/MR Admitted at June 8th Obstructive Jaundice + Treatment from ER
1430151 2019 at 10.00 PM Abdominal pain + • IVFD crystalloid
Hepatomegali + Melena + • Inj. antibiotic
Anemia • Inj. analgetic
• Inj. antifibrinolitik
• Po. antipiretic
• Urin catheter
• NGT
Consult to Digestive Surgery
• Hospitalized ICU
• PRC Transfusion 1kolf/day
until Hb more than 10
• CT Scan abdomen with
contrast
 Patient List
No Identity Admission to ER Diagnosis Treatment

7. Mr. Saiful bahri/49 Admitted June 9th Clinical Diagnosis : Urinary Treatment from ER
yo/MR 1430156 2019 at 00.30 AM Retention • Check DL, Ur/cr, PT/APTT
Etiological Diagnosis : • BOF include penis
Anterior Urethral Stone • Pro meatotomy
(fossa Naviculare)
Complication Diagnosis : - Consult to Urology
Other Diagnosis : HT gr 2 • Dorsal meatotomy
 1. Mrs. Asnah/59yo/MR 1427642
Admitted June 8th at 05.00 PM
Chief Complain:
Full at lower abdomen
History taking :
patients complain of feeling full at the bottom, complaints have been felt for 3 months, sometimes pain,
dull pain, especially if the patient is seated. Patients also complain of frequent urination, especially urine at
night, blood urine (-), history of sand / stone urine (-), vaginal bleeding (-), defecate (+), but feeling like
pressure near the anus, chapter blood (-), solid consistency. Patients complained of decreased appetite
lately, so that body weight decreased 10kg / 3 this month, tightness (-).

History of Family Illness : (-)

Vital Sign
BP : 140/80 mmHg
RR : 22x/minute
HR : 98 x/minute (strong and regular pulse)
Temp : 36,9 C
VAS : 3/10
SpO2 : 99% without O2 supply
GCS : E4V5M6
Physical Examination
• pale conjungtiva (-/-), sclera icteric (-/-), pupil equal 3 mm/3 mm, light reflex (+)
Head/Neck • enlargement lymph node (-), increase jugular vein (-)

• I : symmetric respiratory movement, retraction (-)

Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)

• I : distension (-) mass (-)

• A : bowel sound (+) 8-9x/minute, metallic sound (+)
Abdomen • P : soft, defense muscular (-), tenderness (+) ar Suprapubic
• P : Tympani

Extremities • Warm extremities, edema (-/-), parese (-/-)

Digital Rectal Examination
I : haemorrhoid (-), laceration (-), mass (-), fistle (-)
P:
- Spincter ani tone : normal limit
- Ampulla was not collapse
- Rectal mucosa slipperly, regular
- Mass (+), pressing anus from extralumen, hard consistency, regular border
- Tenderness (-)
- Prostate : soft, symmetric, upper pole was palpated, median sulcus palpated,
nodule (-)
- Handscon : Feces (-), blood (-)
Clinical Pictures
 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 6,1 12,00-16,00 g/dl
Leukosit 9,7 4,0-10,5 ribu/ul
Eritrosit 2,89 3,90-5,50 juta/ul
Hematokrit 19,2 37,00-47,00 vol%
Trombosit 607 150-450 ribu/ul
RDW-CV 20,2 11,5-14,7 %
MCV 66,4 80,0-97,0 fl
MCH 21,1 27,0-32,0 pg
MCHC 31,8 32,0- 38,0 %
Gran % 69,9 50,0-70,0 %

Limfosit % 21,7 25,0-40,0 %

MID % 6,5 4,0-11,0 %

Gran # 6,79 2,50-7,00 ribu/ul

Limfosit # 2,11 1,25-4,0 ribu/ul

MID # 0,63
 Pemeriksaan Hasil Nilai Rujukan

PT 12,7 9,9-13,5 detik

INR 1,19

APTT 27,6 22,2-37,0 detik

GDS 93 <200

SGOT 20 0-46 U/l

SGPT 12 0-45 U/l

Ureum 31 10-50 mg/dl

Creatinin 0,75 0,7-1,4 mg/dl

Natrium 141 135-146 mmol/l

Kalium 3,8 3,4-5,4 mmol/l

Chlorida 109 95-100 mmol/l

Thorax X Ray
MSCT abdomen
 Diagnosis
Massa pelvic susp rhabdomiosarcoma
Management
• Treatment from ER • Consult to Digestive Surgery
• IVFD Nacl 20 tpm • Hospitalized
• Inj. Antrain 3x1gr • PRC transfusion until hb >10
• Inj. Ranitidin 2x50mg
 2. Mr. Muhammad Taufik/20yo/MR 1430135
Admitted June 8th 2019 at 06.00 PM

Chief Complain: Right knee and hand pain

History taking:
Patients present with complaints of right knee and hand pain since 30 minutes before entering the hospital. The
patient was cutting wood using a grinding wheel and suddenly the grinding was released and hit the right knee
and the patient's right hand. The patient complained of pain, persistent pain accompanied by active bleeding
that appeared on the patient's right knee, no decrease in consciousness, no dizziness, no nausea or vomiting,
no seizures, no shortness of breath. The patient was then taken to the Ulin hospital to get further treatment.

History of Past Illness : (-)

History of Family Illness : (-)
Primary Survey
• Airway :
• Clear, without C-Spine control
• Breathing :
• Lesion (-), symmetrical movement, RR : 20x/minute (regular), vesicular breath
sound Rh (-/-) Wh (-/-). SpO2 : 98% without O2
• Circulation :
• HR : 90x/minute (regular, strong pulse), BP : 110/80 mmHg, warm extremities.
• Disability :
• GCS E4V5M6, pupil equal 3 mm/3 mm, direct light reflex (+/+), lateralization
(-)
 Secondary Survey
• Allergy : (-)
• Medication : (-)
• Past Illness : (-)
• Last Meal : 05.00 pm
• Environment : at Gambut
 • pale conjungtiva (-/-), sclera icteric (-/-), pupil 3mm/3mm. Light reflex (+/+)
Head/Neck • enlargement lymph node (-)

• I : symmetric respiratory movement, retraction (-), bruise (-)

• P : symmetric vocal fremitus
Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)

• I : Lesion (-) Distension (-)

• A : Bowel sound (+)
Abdomen • P : Soepel (+), defence muscular (-)
• P : thympani (+)

Extremities • warm extremities in all regio, parase (-), edem (-)

Local Status
Ar manus dextra
L: Vulnus laceratum (+), facia (+)
F: crepitation (-), akral hangat, CRT < 2 sec,
tenderness (+)
M: ROM flexion active & passive (+)

Ar genu anteromedial dextra

L: Vulnus laceratum (+), fascia (+)
F: crepitasion (-), akral hangat, CRT < 2 sec,
tenderness (+)
M: ROM flexion active & passive genu joint normal
ROM extension active & passive genu joint normal
Genu Xray
 Diagnosis

Open fracture at right patella chipping with partial rupture patellar

tendon.
 Management
Treatment in ER
• Debridement
• Primary suture
• Inj Tetagam 250 ui IM
• Po cefixime 2 x 200mg
• Po Mefenamic acid 3 x 500mg
• Patient out by permission
Post Primary suture
 3. Mrs. Mariati/61yo/MR 1430139
Admitted June 8th 2019 at 07.32 PM

Main complaint: unable to move lower leg

Patient is a referal from a kandangan hospital with a diagnosis of TB
spondylitis. The patient initially fell 3 months ago, after falling the patient
complained pain when sitting which appeared suddenly and continuously and
over time the patient was unable to stand up. The patient was diagnosed with
TB and had been treated for 2 months. The patient also complained of
coughing at night since 1 month and sometimes there was vomiting and
according to family patient had lost weight for 2 months more than 10kg. The
patient can still feel when urinate and defecating.

History of past illness: HT (-) DM (-) heart disease (+)

History of Family illness: HT (+) DM (-) heart disease (-), TB (+)
 Vital Sign
• Compos Mentis, GCS E4V5M6
• BP : 100/70 mmHg
• HR : 103 bpm, regular and strong
• RR : 20 bpm, SpO2 : 99% without O2
• Tax : 36.1 C
• VAS: 5/10
 Physical Examination
• Head & Neck
• anemic conjunctiva (-/-), icteric sclera (-/-), Lymph nodes enlargement (-/-), JVP enhancement
(-/-)
• Chest
• I : Symmetric respiratory movement, no retraction,
• P : Symmetric VF
• P : Sonor at all lung fields, tenderness (-/-)
• A : symmetric VBS, rhonchi (-/-), wheezing (-/-)
• Abdomen
• I : Distension (-)
• A : Bowel sound (+) normal
• P : mass palpable (-), tenderness (-)
• P : Tymphanic
• Extrimities
• Warm extremities, edema (-/-/-/-), parese (-/-/-/-), paralyzed (-/-/+/+) Wound (-/-/-/-)
 Spinal Cord Examination

• Sensory and motoric paralysis as high as T 7 level

• Sacral Sparing
• BCR (+)
• Anal wink (+)
• Great toe flexion (+)
Neurological state
• Shoulder shruk : 5/5 • Knee flexion : 4/4
• Shoulder abduction : 5/5 • Ankle dorsoflexion : 4/4
• Elbow flexion : 5/5 • Ankle plantarflexion : 4/4
• Elbow extension : 5/5 • Great toe flexion : 4/4
• Wrist flexion : 5/5 • Physiological reflex : +/+
• Wrist extension : 5/5 • Patological reflex : +/+
• Finger abduction : 5/5 • Urinate : DC
• Finger adduction : 5/5 • Defecate : (+)
• Hip flexion : 4/4
Clinical Picture
Chest X Ray in Kandangan Hospital
Thoraco Lumbal X Ray
MRI Kandangan Hospital
 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 9,8 12,00-16,00 g/dl
Leukosit 9,6 4,0-10,5 ribu/ul
Eritrosit 3,7 3,90-5,50 juta/ul
Hematokrit 27,6 37,00-47,00 vol%
Trombosit 909 150-450 ribu/ul
RDW-CV 16,4 11,5-14,7 %
MCV 74,6 80,0-97,0 fl
MCH 26,5 27,0-32,0 pg
MCHC 35,5 32,0- 38,0 %
Gran % 77,6 50,0-70,0 %
Limfosit % 12,2 25,0-40,0 %
Gran # 7,46 2,50-7,00 ribu/ul
Limfosit # 1,17 1,25-4,0 ribu/ul
 Pemeriksaan Hasil Nilai Rujukan
PT 12,7 9,9-13,5 detik
INR 1,19
APTT 23,1 22,2-37,0 detik
GDS 97 <200
SGOT 32 0-46 U/l
SGPT 29 0-45 U/l
Ureum 21 10-50 mg/dl
Creatinin 0,43 0,7-1,4 mg/dl
Natrium 129 135-146 mmol/l
Kalium 3,8 3,4-5,4 mmol/l
Chlorida 88 95-100 mmol/l
 Working Diagnosis

Myeloradculopathy at level T7 due to burst fracture at vertebra T7 dan

T9 due to susp. Spondylytis tb dd/ metastase bone disease
 Management
ER Treatment:
• IVFD Nacl 20 tpm
• Inj. Ketorolac 3x30mg
• Inj. Ranitidin 2x50mg

Consult to Orthopaedic:
• Hospitalized
• Continue OAT
 4. Mrs. Mariana/52yo/MR 0630190
admitted June 8th 2019 at 09.00 PM
Chief Complain : Nausea and vomiting
History :
Patientscame to emergency department with complaints of nausea and vomiting since a
month ago. Today vomiting more than 5 times, filling mucus and clear liquid, once vomiting
1 glass of mineral water. The patient also complained of headaches since 1/2 month before
entering hospital and did not stop or improve with any medication. Patients also complain of
blurred vision, reduced hearing and buzzing and disturbed balance. The patient also
complained of tingling and pain in the spine to the feet. Patient was a referral from
Banjarmasin SIAGA Hospital. The patient initially had a lump on the left 1 year before
entering the hospital and was carried out by the MRM. At present the patient has decreased
appetite. urination and defecation within normal limits.
History of Past Illness : HT (-), DM (-)
History of Family Illness : Tumour (-), DM (-)
• Biopsy history (+)
Adjuvant chemotherapy (+) history 6 times

Risk factors: Use of the 11-year birth control pill

Menarche age (forgot)
Number of children: 3 people
Age when giving birth to first child = 16 years
History of lactation (+)
Menopause (+)
Family history (-)
 Vital Sign
• BP : 120/80 mmHg
• HR : 63 bpm (regular, strong)
• RR : 20 tpm
• Tax : 36.80C
• Karnofsky Score : 50-60%
• SpO2 : 98% without O2 supply
Physical Examination
• Head : pale conjunctiva (-/-), sclera icteric (-/-), pupil equal 3 mm|3 mm, light reflex +|+
Head • Mouth : moist mucous membrane
• Neck : enlargement of the lymph node (-) increase jugular vein pressure (-)

• I : symmetrical respiratory movement, retraction (-)

Chest • P : sonor +|+
• A : vesicular breath sound, no ronchi , no wheezing

• I : distension (-), venectation (-)

Abdomen • A : bowel sound (+) 8-9x /minute
• P : soft, tenderness (-), liver / spleen / mass not palpable
• P : tympany

Extremities • warm extremities, parese -|-, edema (-)

Local state
A/r Mammae sinistra
I : Scar mastectomy (+), nodules (-), ulcer (-), pus (-) discharge (-
), hyperemis (-)
P: Nodules (-), NT (-)

A/r Mammae dextra

I : nodules (-), ulcer (-), pus (-) discharge (-), hyperemss (-)
P : Mass (-), NT (-)

Ar Axilla dextra:
Enlargement KGB (-), NT(-)

Ar Axilla sinistra
Enlargement KGB (-), NT(-)
 Laboratory Finding June 8th 2019
Examination Result Normal Value
Hemoglobin 13,5 12,00-16,00 g/dl
Leukosit 11,1 4,0-10,5 ribu/ul
Eritrosit 4,58 3,90-5,50 juta/ul
Hematokrit 38 37,00-47,00 vol%
Trombosit 237 150-450 ribu/ul
RDW-CV 12,7 11,5-14,7 %
MCV 83 80,0-97,0 fl
MCH 29,5 27,0-32,0 pg
MCHC 35,5 32,0- 38,0 %
Gran% 80,6 50 – 81
Limfosit% 11,4 20 – 40
MID % 8
Gran# 8,94 2,5 – 7
Limfosit# 1,27 1,25 – 4
 Laboratory Finding
Examination Result Normal Value
PT 11,7 9,9 – 13,5
INR 1,08
APTT 22,3 22,2 – 37,0
Random Blood Glucose 98 <200.00 mg/dl
Albumin 4,1 3,5-5,2 g/dl
SGOT 22 5-34 u/l
SGPT 13 0-55 u/l
Ureum 19 0-50 mg/dl
Creatinin 0,62 0.57-1.11 mg/dl
Natrium 130 135-146 mmol/L
Kalium 3,8 3,4-5,4 mmol/l
Chlorida 92 95-100 mmol/l
 Thorax Photo
03/05/2019

Conclusion
• Radiologically cast within normal
limits
USG 30/01/2019
PA Result
 Working Diagnosis
Malignant Neoplasma of the Breast sinistra + susp. Brain metastasis
post MRM post Kemoterapi subtype her 2 +3
 Management
Treatment from ER:
Consult to oncology surgery:
• IVFD NS 20 tpm
• Hospitalized
• Ro thorax
• Ct scan kepala with contrast
• USG
• CEA/ Ca 15-3
 5. Mr. Badran/ 46 yo/ MR 1430149/
admitted June 8th 2019 at 09.45 PM

Chief Complain: pain in left temple

History taking:
Patients come to emergency room after a motorcycle accident 1 hour before admitted to hospital. The patient
fell from the motorbike after being hit by a car from the side. The patient was in passenger seat and drive with
his colleague and the patient uses a helmet. The patient falls to the asphalt with the forehead and temple
position first touching the asphalt. The patient is still able to move both arms and legs and feel no pain when
moved. The patient denies there is a tingling in his legs and hands. After an unconscious (-) accident, vomiting (-
), blurred vision (-), nose and mouth bleeding (-), seizures (-), shortness of breath (-). The patient when asked
about the incident seemed confused and difficult to remember clearly what happened.

History of Past Illness : (-)

History of Family Illness : (-)
Primary Survey
• Airway :
• Clear, without C-Spine control
• Breathing :
• Lesion (-), symmetrical movement, RR : 20x/minute (regular), vesicular breath
sound Rh (-/-) Wh (-/-). SpO2 : 98% without O2
• Circulation :
• HR : 64x/minute (regular, strong pulse), BP : 140/100 mmHg, warm
extremities.
• Disability :
• GCS E4V5M6, pupil equal 3 mm/3 mm, direct light reflex (+/+), lateralization
(-)
 Secondary Survey
• Allergy : (-)
• Medication : (-)
• Past Illness : (-)
• Last Meal : 09.00 pm
• Environment : Pulau laut street at Banjarmasin
 • pale conjungtiva (-/-), sclera icteric (-/-), pupil 3mm/3mm. Light reflex (+/+)
Head/Neck • enlargement lymph node (-)

• I : symmetric respiratory movement, retraction (-), bruise (-)

• P : symmetric vocal fremitus
Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)

• I : Lesion (-) Distension (-)

• A : Bowel sound (+)
Abdomen • P : Soepel (+), defence muscular (-)
• P : thympani (+)

Extremities • warm extremities in all regio, parase (-), edem (-)

Local Status
Status lokalis a.r. Palpebra superior sinistra:

I : swelling (-), vulnus (+) laceratum size 4 cm x 1 cm x

0,5 cm muscle base, with irregular border and blunt
edge, deformation (-).

P: tenderness (+), krepitasi (-).

 Diagnosis

Lacerated Wound at region palpebra superior sinistra

 Management
Treatment in ER
• Wound toilet
• Primary suture
• Inj Tetagam 250 IU
• Po Cefadroxyl 2x500mg
• Po mefenamic ac 3x500mg
• Patient out by permission
Post primary suture
 6. Mr. Birhan /49 yo/MR 1430151
Admitted at June 8th 2019 at 10.00 PM

Chief Complain:
Pain at right upper abdomen
History taking :
Patient complained abdominal pain since 15 days ago, pain suddenly appeared at the beginning of the
abdominal pain felt right above and then spread to the waist then felt all abdominal region, abdominal pain
was sore and pain was intermittenly, pain was reduced if the patient lay down.
The patient also complained about black (+) defecation since 15 days ago and until now, soft defecation 2
times a day, patient also complained of nausea and vomiting every meal, vomit contained food. Vomiting
mixed with blood (-). Patients also complained of yellow eyes since 7 days and also complained about yellow
palms for 3 days.
The patient were a reference from the Anshari Saleh Hospital, before the patient was treated in Ansyari
Saleh hospital for 5 days and when he was treated the patient had fever (+) 3 days ago. During treatment the
patient was transfused in 4 bags of PRC. The patient also had an ultrasound of the abdomen and the result
was hepatomegaly + Acute kidney injury.
History of Family Illness : (-)
Vital Sign
BP : 100/60 mmHg
RR : 20x/minute
HR : 98 bpm, (weak and regular pulse)
Temp : 37,1oC
VAS : 5/10
SpO2 : 99% without O2 Supply
GCS : E2V2M4
Physical Examination
• pale conjungtiva (-/-), sclera icteric (+/+), pupil equal 2 mm/2 mm, light reflex (+)
Head/Neck • enlargement lymph node (-), increase jugular vein (-)

• I : symmetric respiratory movement, retraction (-)

Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)

• I : distension (-), mass (-), scara (-)

• A : bowel sound (+) 5-7x/minute
Abdomen • P : liver palpated 3 cm BAC, regular border, nodule (-), spleen cannot palpated, mass
(-), defense muscular (-), tenderness sde
• P : tympani

Extremities • Cool extremities, edema (-/-), parese (-/-)

Digital Rectal Examination
I : haemorrhoid (-), laceration (-), mass (-), fistle (-)
P:
- Spincter ani tone : normal limit
- Mucosa was not slippery
- Ampulla was not collapse
- Mass (-)
- Tenderness (-)
- Prostate : soft, symmetric, upper pole was palpated, median sulcus was
concave
- Handscon : Feces (+) black colour, blood (-)
Clinical Pictures
Laboratory Finding 08/06/19
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 9,2 12,00-16,00 g/dl
Leukosit 24,1 4,0-10,5 ribu/ul
Eritrosit 3,88 3,90-5,50 juta/ul
Hematokrit 29,2 37,00-47,00 vol%
Trombosit 519 150-450 ribu/ul
RDW-CV 17,8 11,5-14,7 %
MCV 75,3 80,0-97,0 fl
MCH 23,7 27,0-32,0 pg
MCHC 31,5 32,0- 38,0 %
 Laboratory Finding 08/06/2019

Examination Result Normal Value

PT 10,8 9,9-13,5 detik

INR 1,0

APTT 25,6 22,2-37,0 detik

GDS 90 <200

Albumin 2,1 3,5 - 5,2 g/dl

Total Bilirubin 4,1 0,2 – 1,2 mg/dl

Direct Billirubin 3,8 0,0 – 0,2 mg/dl

Indirect Billirubin 0,3 0,2 – 0,8 mg/dl

SGOT 62 0-46 U/l

SGPT 27 0-45 U/l

Ureum 47 10-50 mg/dl

Creatinin 0,54 0,7-1,4 mg/dl

Thorax X Ray
USG Abdomen
 Diagnosis
Obstructive Jaundice + Abdominal pain + Hepatomegali + Melena +
Anemia
Management
Treatment from ER Consult to Digestive Surgery
• IVFD NS 20 tpm • Hospitalized ICU
• Inj. Antrain 3x1gr • PRC Transfusion 1kolf/day until Hb
• Inj. Kalnex 3x500mg more than 10
• Inj. Ceftriaxone 2x1 • CT Scan abdomen with contrast
• Po. Pct 3 x 500 mg
• DC
• NGT
 7. Mr. Saiful bahri/49 yo/MR 1430156
Admitted June 9th 2019 at 00.30 AM

Chief Complain:
Couldn’t urinate
History taking :
Patients cannot urinate start at 18 hours before admitted ti hospital. The patient cannot urinate because
he feels there was a blockage in his urethra. The patient is still able to urinate, but must be with straining but
only a little out. Patients also complain of pain in the tip of their penis. History of fever (-), blood urinary
history (-), history of stone / sand urine 1 item 3 days ago the size of rice, fever (-). History of left waist pain
since 1 week ago, pain appeared just like that, since 3 days urination was not smooth.
History of pus in urethra (-), Drink lots of water, water drunk from boiled water, History of drinking energy
drink routinely (-)

History of past illness : Gout (-), HT (+) routinely taking captopril, DM (-)
History of Family Illness : (-)
Vital Sign
BP : 140/100 mmHg
RR : 20x/minute
HR : 98 bpm (strong and regular pulse)
Temp : 36,6oC
VAS : 6/10
SpO2 : 99% without O2
GCS : E4V5M6
Physical Examination
• pale conjungtiva (-/-), sclera icteric (-/-), pupil equal 3 mm/3 mm, light reflex (+)
Head/Neck • enlargement lymph node (-), increase jugular vein (-)

• I : symmetric respiratory movement, retraction (-)

Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)

• I : distension (-), mass (-), scar (-)

• A : bowel sound (+) 6-8x/minute
Abdomen • P : soft, tenderness (-), liver / spleen / mass not palpable
• P : tympani

Extremities • Warm extremities, oedema (-/-), parese (-/-)

 Urologic Status
CVA : Genitalia
• I : flat, lesion (-), hematoma (-), mass (-), eritema (- • Penis :
/-) • I : stone appereance at OUE, swelling (-),
• Pal : kidney, mass (-/-), tenderness (-/-) haematoma (-), bloody discharge (+)
• P : stone was palpated at OUE up to fossa
• Per : knocked kidney pain : (-/-)
navicularis
Flank area :
• OUE : bloody discharge (-), pus (-)
• I : flat, lesion (-/-), hematoma (-/-), mass (-/-)
• Scrotum : erythema (-/-), swelling (-/-), tenderness
• P : tenderness (-/-), mass(-/-) (-/-)
Suprapubic
• I : distension (+), mass (-), scar (-)
• P : tenderness (+), cystic mass (+) 3 finger from
symphisis, dull percussion (+)
Digital Rectal Examination
I : haemorrhoid (-), laceration (-), mass (-), fistle (-)
P:
- Spincter ani tone : normal limit
- Mucosa was slippery
- Ampulla was not collapse
- Mass (-), tenderness (-)
- Prostate : soft, symmetric, upper pole was palpated, median
sulcus was concave
- Handscon : Feces (+), blood (-)
Clinical Pictures
Radiology Examination
 Diagnosis
• Clinical Diagnosis : Urinary Retention
• Etiological Diagnosis : Anterior Urethral Stone (fossa Naviculare)
• Complication Diagnosis : -
• Other Diagnosis : HT gr 2
Management
Treatment from ER Consult to Urology
• Check DL, Ur/cr, PT/APTT • Dorsal meatotomy
• BOF include penis
• Pro meatotomy
Post Meatotomy