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ANAMNESIS
Chemical burn injury
He got poured by chemical fluid on his face, chest, and back by
his wife
(about 3 days before admission)
(Reffered from AR Bunda Hospital)
PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. BP : 130/80 mmHg
PR : 88 x/mnt
T : 36,8 C
D. GCS : E4M6V5: Pupil Isochor, Light Reflexes +/+
SECONDARY SURVEY
DIAGNOSIS
Chemical burn injury (cuka para) 36 %
MANAGEMENT
Irigation
IVFD RL gtt 50 / m
Inj Ceftriaxon 1gram/ 12 hours IV
Inj Ketorolac 30mg/ 8 hours IV
Inj Ranitidin 50mg/ 12 hours IV
Inj ATS 1500 IU IM
PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. BP : 120/70 mmHg
PR : 80 x/mnt
T : 36,5 C
D. GCS : E4M6V5: Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY
DIAGNOSIS
Chemical burn injury (cuka para) 12%
MANAGEMENT
IVFD RL gtt 30/m
Inj Ceftriaxon 1gram/ 12 hours IV
Inj Ketorolac 30mg/ 8 hours IV
Inj Ranitidin 50mg/ 12 hours IV
Inj ATS 1500 IU IM
Irigation
ANAMNESIS
Fire Burn injury
He got burned when he was playing with matches
(about 12 hours before admission)
PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. PR : 90 x/mnt
D. GCS : E4M6V5: Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY
DIAGNOSIS
Fire Burn injury grade IIA-B 8%
MANAGEMENT
IVFD RL gtt XV / m
Inj Ceftriaxon 500mg/ 12 hours IV
Inj Paracetamol 250mg/ 8 hours IV
Inj ATS 1500 IU IM
Pro debridement
PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. BP : 110/80 mmHg
PR : 82 x/mnt
T : 36,5 C
D. GCS : E2M5V3: Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY
DIAGNOSIS
Moderate head injury of GCS 10 + cerebral edema
MANAGEMENT
O2 10L/m
Head up 30
NGT
IVFD NaCl 0,9% gtt XX/minutes
Inj ceftriaxon 1gram/12 hours IV
Inj Tramadol 100mg/ 12 hours IV
ANAMNESIS
Decrease of consiousness after having a traffic accident
His motorcycle that he drive got slipped. He fell with head hit a
hard thing
(about 10 days before admission)
Refered from muara enim Hospital
PRIMARY SURVEY
A. Clear
B. RR : 20 x/mnt
C. BP : 110/80 mmHg
PR : 88 x/mnt
D. GCS : E4M5V4 : 13, Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY
DIAGNOSIS
Moderate head injury of GCS 13 + cerebral edema
MANAGEMENT
O2 10L/minutes
Head up 30
IVFD NaCl 0,9% gtt XX/minutes
Inj ceftriaxon 1gram/12 hours IV
Inj Tramadol 100mg/ 12 hours IV
ANAMNESIS
Unable to urinate
About 6 hours before admission, she complained unable to
uninate, nausea (-), vomite (-), fever (-)
History of bloody spill on catheter isertion before
History of difficult to urinate since 1 year ago
History of weak stream urine (+)
History of night urinate (+) 6-10 /night (-)
VITAL SIGNS
Sense : CM
BP : 150/100 mmHg
PR : 90x/mnt
RR : 20 x/mnt
T : 36,6 C
PHYSICAL EXAMINATION :
On The Right CVA Region :
I : Bulged (-)
P: Pain (-)
On The Left CVA Region :
I : Bulged (-)
P: Pain (-)
On the suprapubic region
I : Bulging (+)
P : dull
On the genitalia externa region
I : bloody discharge(-)
Urethrogram
stricture (-) rupture (-) contras extravasation (-)
USG
Bilateral hydronephrosis
Full blast
USG TUG
(dr. Hanna Marshinta,SpRad)
Bilateral hydronephrosis
prostat hyperplasia
LABORATORY FINDING:
Hb : 14,2 g/dl ( 12-16 g/dl )
Ht : 43 vol % ( 37-43 vol % )
WBC : 13.700 / mm3 ( 5000-10000/mm3 )
Trombo : 285.000 / mm3 ( 200.000-500.000/mm3)
BSS : 115 mg/dl
Ureum : 34 mg/dl ( 15-39 mg/dl )
Creatinin : 1,60 mg/dl ( 0,6-1,0 mg/dl )
Na : 144 mmol/l ( 135-155 mmol/l )
K : 4,8 mmol/l ( 3,5-5,5 mmol/l )
WORKING DIAGNOSIS
Urine retention (R33.9)
PRIMARY DIAGNOSIS
BPH
SECONDARY DIAGNOSIS
Hipertension
COMPLICATION DIAGNOSIS
Bilateral Hydronephrosis (N13.2)
MANAGEMENT
- IVFD RL gtt XX/minute
- Inj Ceftriaxone 1 gr/ 12 hours IV
- suprapubic punction
- Cystostomi
ANAMNESIS
Increased head circumference
About 1 year ago her doughter head circumference getting larger
history of VP shunt 7 month ago
Patient often get fever and followed by seizure
Stomatch ache after VP shunt (+)
VITAL SIGNS
PR : 102 x/mnt
RR : 30 x/mnt
T : 36,4 C
PHYSICAL EXAMINATION :
On The head Region :
I : macrocephalus (+)
VP shunt expose
DIAGNOSIS
Hydrochepalus with VP shunt expose
MANAGEMENT
- IVFD D5 NS gtt X/m
- Inj Ceftriaxone 250 mg/ 12 hours
- Inj Paracetamol 100mg/8 hours
- Remove VP shunt
INTRA OPERATIVE
We found VP shunt expose, we perform lazy-s incision on two
side
We perform VP shunt removal
Continued with refreshing and undermining
ANAMNESIS
Abdominal Distended
About 1 year before admission his mother complained her
doughter stomach getting distended. Vomite (+) since 4 days
before admission, the content is what she drink
Diarhaea (+) since 4 days before admited
fever (-), history of late meconium (+), history of constipation (+)
Refered from Kayu Agung Hospital
VITAL SIGNS
PR : 92x/mnt
RR : 24 x/mnt
T : 36,5 C
PHYSICAL EXAMINATION :
On The abdominal Region :
I : Distended
P : Soft
P : Timphani
A : Bowel Sound (+)
DRE:
Sprouting stool
LABORATORY FINDING:
Hb : 12,3 g/dl ( 12-16 g/dl )
Ht : 35 vol % ( 37-43 vol % )
WBC : 19.600/ mm3 ( 5000-10000/mm3 )
Trombo : 421.000 / mm3 ( 200.000-500.000/mm3)
DIAGNOSIS
Suspect Hirschsprung Associated Enterocolitis
MANAGEMENT
IVFD D5 NS gtt 40/m (mikro)
- Inj Ceftriaxone 250 mg/ 12 hours
- Inj metronidazole 100mg / 8 hours
- Rectal wash out
4. Isti Waidah/ / 40 Years Old
Admitted on Wednesday, June 14th 2017 at 1.10 pm
ANAMNESIS
Bloody urinate
About 10 days before admission she complain bloody urinate
and difficult to urinate.
History of histerectomy June, 2016 at RSUP dr. Mohammad
Hoesin Palembang
PA : Endometrioid carcinoma grade II at uterus that covered
upper third cervix, all uterus lower segment, and a half of
myometrium
History of chemotherapy, 6x untill December, 2016
History of hipertension since 1 year ago
.
VITAL SIGNS
Sense : CM
BP : 140/110 mmHg
PR : 82x/mnt
RR : 22 x/mnt
T : 36,6 C
PHYSICAL EXAMINATION :
On The abdominal region:
I : flat, operation scar(+)
P : soft
P : timphani
A : Bowel sound (+)
On The Right CVA Region :
I : Bulged (-)
P: Pain (-)
On The Left CVA Region :
I : Bulged (-)
P: Pain (-)
On the suprapubic region
I : Bulging (-)
P : dull (+)
On the genitalia externa region
I : bloody discharge(-)
USG (IGD)
Bilateral hydronephrosis
CT SCAN (17 february 2017)
right hydronefrosis + right upper hydroureter
LABORATORY FINDING:
Hb : 8,9 g/dl ( 12-16 g/dl )
Ht : 26 vol % ( 37-43 vol % )
WBC : 12.400 / mm3 ( 5000-10000/mm3 )
Trombo : 453.000/ mm3 ( 200.000-500.000/mm3)
BSS : 98 mg/dl
Ureum : 123 mg/dl ( 15-39 mg/dl )
Creatinin : 11,8 mg/dl ( 0,6-1,0 mg/dl )
Na : 151mmol/l ( 135-155 mmol/l )
K : 4,1 mmol/l ( 3,5-5,5 mmol/l )
WORKING DIAGNOSIS
Gross hematuria, Obstructive Nefropathy
PRIMARY DIAGNOSIS
Suspect metastatic of Endometrioid carcinoma of Bladder
SECONDARY DIAGNOSIS
Endometrioid Carcinoma post HTSOB post chemotheraphy,
hypertension
COMPLICATION DIAGNOSIS
Bilateral Hydronephrosis, Anemia (N13.2)
CKD Stage V
MANAGEMENT
- IVFD RL gtt XX/minute
- Inj Ceftriaxone 1 gr/ 12 hours
- 3 way catheter irigation
- transfusion
- Plan to right nephrostomi
- Join Care Internal Department: pro Hemodialisa
ANAMNESIS
Abdominal distended
Since 1 week before admission the patient complain of
Abdominal distended, defecate (-), flatus (-), vomites (+), fever (-)
History of bowel change habit (-), decreasing of body weight (+)
VITAL SIGNS
Sense : CM
BP : 110/90 mmHg
PR : 108x/mnt
RR : 24 x/mnt
T : 37,1 C
PHYSICAL EXAMINATION :
On The abdominal region:
I : dome shape, bowel contour (+)
bowel movement (+)
P : soft
P : timphani
A : Bowel sound (+) increase
DRE:
I : TSA was good, ampula colaps,
smooth mucosa, no palpable mass
USG
(Sekayu Hospital) dr. Agnes, SpRad
Ileus
sludge gall blader
X-Ray
Plain abdominal X Ray
MANAGEMENT
- IVFD RL gtt XX/minute
- Inj Ceftriaxone 1 gr/ 12 hours IV
- inj Metronidazole 500mg/ 8hours IV
- inj Ranitidin 50 mg/ 12 hours IV
- fasting
- NGT, Catheter
- Laparotomy exploration
VITAL SIGN
Sens : CM
TD : 130/80 mmHg
N : 96 x/mnt
RR : 21 x/mnt
T : 36,5C
PHYSICAL EXAMINATION
THERAPY:
IVFD RL gtt XXX/minute
- Inj Ceftriaxone 1 gr/ 12 hours IV
- inj Metronidazole 500mg/ 8hours IV
- inj Ranitidin 50 mg/ 12 hours IV
- fasting
- Electrolite correction
- Digoxin 0,25 mg
- Amiodaron 100mg (drip)
- Laparotomy exploration
VITAL SIGN
Sens : E2M3VT : 5T
TD : 150/100 mmHg
N : 94 x/mnt
RR : 20 x/mnt
T : 36,5C
RADIOLOGY FINDING
CT cranium
Hipodens lession at left hemispher
DIAGNOSIS
Decreasing of consiousness of GCS 5T due to non hemorhagic
CVD
THERAPY:
O2 10L/minutes
Head up 30
IVFD NaCl 0,9% gtt XX/minutes
Inj ceftriaxon 1gram/12 hours IV
Inj Tramadol 100mg/ 12 hours IV
Craniectomy decompression
PREOPERATIF DIAGNOSIS
Acute appendicitis
INTRA OPERATIF
We found appendix that inflammed at pelvinal site
We perform appendektomi
PREOPERATIF DIAGNOSIS
G6P3A2 32 weeks gravid with head presentation fetus+ DKP +
anhidramnion + PEB
INTRA OPERATIF
Blader mucosa we suture with 3.0 plain continous
Blader seromuscular we suture with 3.0 PGA interupted