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Emergency ReportMay 24th - 25th, 2014
Co-Ass on duty: Redha, Fath, Ferisa, Shinta, Fatimah, Sari
Resident on duty:Dr. Andika August Winata
Chief on duty:Zainul Muttaqien
Oncology surgery : -
Digestive surgery : 1
Thorax cardiovascular surgery :
Plastic surgery :
Urology surgery : -
Neurosurgery : -
Pediatric surgery : -
Orthopedic : 1
Total : 3
PATIENT LIST
Patients ListNo Identity Admission to
E.R.Diagnosis Management
1. Siti Mahdalena/ 54 yo/ 111.02.77
24th June 2014/ 14.30
Anterior Dislocation of the right Shoulder Joint
Observation Vital SignAnalgeticH2 Blocker
Consult to Orthopaedic SurgeonClosed Reduction
2. Arbain/ 33 yo/ 11.02.95
24th june 2014/ 19.35
Peritonitis diffuse ec abcess hepar rupture
IVFD NSAntibioticAnalgeticH2 BlockerComplete Lab CheckThorax and BNO rontgenDCNGTFluid Balance
Patients ListNo Identity Admission to
E.R.Diagnosis Management
3. Herman/ 74 yo/ 11.02.96
24th June 2014/ 20.35
Tetanus Phillips score 12 (moderate)Ablett grade III-IV
IVFD RL : D5NGTTetanus Immunoglobulin 3000 IU multi siteAntibioticH2 BlockerDiazepam dripHospitalized
Autonomic Storm 23.00Consult InternistHospitalized ICUDiltiazemMidazolam drip
Patients ListNo Identity Admission to
E.R.Diagnosis Management
4. Bidin/ 47 yo/ 111.02.94
24th June 2014/ 18.55
1. Siti Mahdalena/ 54 yo/ 24th June 2014/ 14.30Chief complain: Pain at right shoulder History : 2 hours before admission, when patient rode
motorcycle in a slippery road, suddenly she fell on her own. She fell with her right hand hit the ground first. After the accident, she felt pain in her left shoulder, and she went to masseur, but her complaint didn’t gone.
List of patient
Primary Survey
• clear, snoring (-) gurgling (-) C-spine control A
• RR : 18/mt, simmetry respiratory movement, VBS simmetry, Rh (-), Wh (-)B
• Pulse 80 t/mt,reguler, lift strong, regular• BP: 120/80 mmHg C• GCS E4V5M6 =15, Pupil 3mm/3mm, light
reflex +/+, DList of patient
A -
M -
P -
L 4 Hour before admission
E On the road
List of patient
Physical Examination• Eyes : Anemic conjunctivae (-), icteric sclerae (-), • Nose : 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 : distention (-), mass (-),• A : Bowel sound (+)• P : Abdominal pain (-), mass (-)• P : Tympani
Abdomen
• Warm, edema (-/-), parese (-/-)Extremities
List of patient
Clinical picture
List of patient
Clinical Picture
Laboratory Findings• Hb : 12,9• WBC : 13,7• RBC : 4,54• Hematocrite : 38,1• Plt : 260• PT/APTT : 9,3/19,3• BSN : 173• SGOT/SGPT : 68/56• Ur/Cr : 17/0,74
• Na : 141,8• K : 5,09• Cl : 105,6
List of patient
Thorax AP 24th June 2014
Shoulder X-Ray 24 June 2014
Shoulder X-Ray Post Reduction
Working Diagnosis
Anterior Dislocation of the right Shoulder Joint
List of patient
Management• Observation Vital Sign• Analgetic• H2 Blocker
Consult to Orthopaedic Surgeon• Closed Reduction
2. Arbain/ 33 yo/ 24th June 2014/ 19.35
Chief complain: pain in stomach History : 5 days before admission, patient complaint that his
stomach getting bigger and he felt pain in his abdomen. Pain start on his upper right abdomen, intermitten, and not spreading to the back. 2 weeks before admission, he had bloody and mucous diarrhea, and felt pain when he defecate, he also had intermitten fever. He also vomiting, 2 times, yellow colored, and his body become yellow (jaundice). No history of trauma, no history of jaundice.
Occupation : merchantHistory of smoke cigarette : 2 packs a dayAlcoholism (+)
List of patient
Vital Sign
• GCS : E4V5M6• HR : 104 x/minutes• BP : 110/80 mmHg• RR : 24 x/minutes• T : 36,9⁰C
Physical Examination
• Eyes : Anemic conjunctivae (-), icteric sclerae (+/+), • Nose : 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 : distention (+), mass (-), • A : Bowel sound (-)• P : Abdominal pain (+), defans muscular (+)• P : Hypertympani
Abdomen
• Warm, edema (-/-), parese (-/-)Extremities
List of patient
Clinical picture
List of patient
Clinical Picture
• Insp :Distended, mass (-)• Ausc: Bowel sound (-)• Palp :Pain (+), defans
muscular (+)• Perk :Hypertympani
Rectal Toucher• Mass (-)• Strong TSA, ampulla not collapse• Slippery mucose• Prostat palpable, 2 bread finger, nodule (-)• Handscoen : mucous (-), blood (-), feces (-)
Laboratory Findings 24th June 2014
• Hb : 12,8• WBC : 29,8• RBC : 40,4• Hematocrite : 38,1• Plt : 709• PT/APTT : 15,3/25,2• BSN : 103• SGOT/SGPT :
43/40• Ur/Cr : 34/0,76
• Bilirubin• Total : 1,85• Direct : 1,80• Indirect : 0,05
• Na : 135,0• K : 4,67• Cl : 99,7
List of patient
Thorax X-Ray 24 June 2014
BNO 3 Position 24th June 2014
BNO 3 Position 24th June 2014
Working Diagnosis
Peritonitis diffuse ec abcess hepar rupture
List of patient
Management• IVFD NS• Antibiotic• Analgetic• H2 Blocker• Complete Lab Check• Thorax and BNO rontgen• DC• NGT• Fluid Balance
3. Herman/ 74 yo/ 24th June 2014/ 20.35 Chief complain: stiffness in mouthHistory : 2 weeks before admission, patient had wound in
his foot, after he fell down and his foot hit the stone, his foot got lacerated wound. He didn’t wash his wound, and this morning he felt stiffness in his mouth when he try to open it. There is no stiffness in stomatch, sweating, and hard to breath. No abnormality in defecate and urinate.
List of patient
Vital Sign
• GCS : E4V5M6
• HR : 88 x/minutes• RR : 22 x/minutes• BP : 170/100 mmHg• T : 36,7⁰C
Physical Examination
• Eyes : Anemic conjunctivae (-), icteric sclerae (-/-), • Nose : 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 : distention (-), mass (-), • A : Bowel sound (+)• P : Abdominal pain (-), defans muscular (-) Epistotonus (-)• P : Tympani
Abdomen
• Warm, edema (-/-), parese (-/-) Spastic (-/-)Extremities
List of patient
Clinical picture
List of patient
Clinical Picture
• Insp :Distended, mass (-)• Ausc: Bowel sound (-)• Palp :Pain (+), defans
muscular (+)• Perk :Hypertympani
Autonomic Storm, 23.00
• HR : 190• RR : 22• TD : 200/100
Laboratory Findings 24th June 2014
• Hb : 14,6• WBC : 6,9• RBC : 5,42• Hematocrite : 44,8• Plt : 291• PT/APTT : 11,4/21,3
List of patient
Working Diagnosis
Tetanus Phillips score 12 (moderate)Ablett grade III - IV
List of patient
Management
• IVFD RL : D5• NGT• Tetanus Immunoglobulin 3000 IU multi site• Antibiotic• H2 Blocker• Diazepam drip• HospitalizedAutonomic Storm 23.00• Consult Internist• Hospitalized ICU• Diltiazem• Midazolam drip
4. Bidin 47 yo/ 24th june 2014/ 18.55 Chief complain: History :
List of patient
Vital Sign
• GCS : E3V5M6
• HR : 94 x/minutes• RR : 28 x/minutes• BP : 180/100 mmHg• T : 36,9⁰C
Physical Examination
• Eyes : Anemic conjunctivae (-), icteric sclerae (-/-), • Nose : 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 : distention (-), mass (-), • A : Bowel sound (+)• P : Abdominal pain (-), defans muscular (-)• P : Tympani
Abdomen
• Warm, edema (-/-), parese (-/-) Extremities
List of patient
Clinical picture
List of patient
Laboratory Findings 24th June 2014
• Hb : 16.0• WBC : 11,4• RBC : 5,40• Hematocrite : 48,7• Plt : 230• PT/APTT : • BSN : 136• SGOT/SGPT :
26/26• Ur/Cr : 38/1,01
• Na : 141,5• K : 3,52• Cl : 101,4
List of patient
Thorax AP 24th June 2014
CT Scan 24th June 2014
CT Scan 24th June 2014
Working Diagnosis
List of patient
Management
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