Emergency Report

July 23th- July 24th 2016

Resident on duty:
dr. Kiki Budiani
Co-ass on duty:
Selvi, Dini, Latif
Bagas, Qayyum, Fifit
General Surgery : -

Digestive Surgery : -

Thorax Cardiovascular Surgery : -

Plastic Surgery : -

Urology Surgery : -

Neuro Surgery : 2

Pediatric Surgery : -

Oncology Surgery : 1

Orthopaedy : 2

Total : 5
 Patient List
No Identity Admission to ER Diagnose Treatment

1. Mrs. Nurul Asma/71 July 23th 2016 Closed Pathological VS Obs

y.o./ 05.00 pm Fracture of Left Tibia Analgetic
0.77.08.38 proximal 3rd Cruris and pelvic xray
undisplaced Tschrene
grd 0 Co to Orthopaedic:
-Posterior slab
-Patient discharge by
permission
 Patient List
No Identity Admission to ER Diagnose Treatment

2. Mr. Reza July 23th 2016 Rhabdomyosarcoma at VS Obs

Kamarullah/ 21 11.30 pm left colli + on IVFD RL
y.o Chemotherapy + H2 blocker
1.20.24.63 pansitopenia + Karnofsky Inj. Tranexamic Acid
Score 50-60 % Inj. Vit.K
Dressing
Complete blood count
Blood Transfusion

Co to Oncology:
Hospitalized
Pro Chemotherapy
 Patient List
No Identity Admission to ER Diagnose Treatment

3. Ch. Faisal July 24th 2016 Moderate head injury + VS Obs

Nurgusnaldi/ 14 00.30 am Closed Fracture Linear at O2
y.o Right Temporooccipital + Head up 30 deg
1.21.85.92 SDH at Right temporal IVFD NS
Antibiotic
Analgetic
H2 blocker
Complete blood count
Head CT-scan

Consult to neurosurgery
Pro Craniotomy
evacuation
Patient Discharge by
request
 Patient List
No Identity Admission to ER Diagnose Treatment

4. Mr. Galih/ 50 y.o July 24th 2016 Mild head injury + close fr. VS Obs
1.21.85.94 03.00 am of right zygoma + SCI due IVFD NS
to Compression Fracture Analgetic
of V. Th 9-10 without H2 blocker
Neurolgical Deficit Complete blood count
Thoracolumbo-sacral
xray

Consult to orthopedic
TLSO

Consult to plastic
surgery:
Conservative
 Patient List
No Identity Admission to ER Diagnose Treatment

6. Mrs. Sukinem/ July 24th 2016 Right hemiparese due to VS Obs

47 y.o 06.00 am SH + ICH at left temporal O2
1.21.85.99 Head up 30 deg
IVFD NS
Antibiotic
Analgetic
H2 blocker
Complete blood count
Head CTScan

Consult to neurosurgery
Craniotomy Evacuation
1. Mrs. Nurul Asma/71 y.o./
0.77.08.38

Chief Complain:
Pain and swelling at left leg

History of Current Disease:

Since 1 hours prior to admission, patient felt while she
swept in her house. She heard cracking sound on her left
leg. Then she felt pain, swelling, and couldn’t walk. History
of swelling or wound in another parts of body (-) history of
trauma before (-). Because of her complained, she brought
to Ulin Hospital for further treatment.
Primary survey :
A : Clear without c-spine control
B : RR 22x/m, symmetrical shape
C : BP: 140/80 HR : 88x/m;
D : GCS 15 E4V5M6, pupil round equal Ø 3 mm, light reflex +/+
lateralization (-) , BH(-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 2 hours before accident
E = Environment  on the house
 • Head : brill haematoma( -/-), hematoma (-)
• Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head • Mouth : moist mucous membrane,
• Neck : Increasion level of JVP (-)

General Status
• I : symmetric respiratory movement, no retraction, bruises (-)
• P : symmetric VF
Chest • P : sonor at all lung fields
• A : symmetric VBS, right =left, rhonchi (-), wheezing (-)

• I : distension (-), bruises (-)

• A : normal Bowel sound
Abdomen • P : defence muscular (-) tenderness (-) , rebound tenderness
(-)
• P :Thymphani (+)

• warm extremities,CRT<2 sec edema (-), parese (-), see local

Extremities status
Local status
a/r Left Leg

• Swelling (+), deformity (+) wound (-)

L

• Tenderness (+), distal neurovascular (+).

F A.tibialis post (+), A. Dorsalis pedis (+)

• ROM active and passive limited due to pain

M
Clinical picture
Cruris Xray
Pelvic Xray
 Working Diagnosis

Closed Pathological Fracture of Left Tibia

proximal 3rd undisplaced Tschrene grd 0
 Management
•VS Obs
Analgetic
H2 Blocker
Cruris and pelvic xray

•Co to Orthopaedic:
Posterior slab
Patient discharge by permission
 2. Mr. Reza Kamarullah/ 21 y.o
1.20.24.63
Chief Complain:
Bleeding from the mass on neck

History of Current Disease:

Since 1 hours before admission, patient complained bleeding from the mass
on his neck. Bleeding was about 1 liter blood. Patient felt fatigue, headache
(+), nausea (+), vomiting (-), hard to breath (-).
History of Past Disease:
Patient had lump/mass on his left neck since 10 months ago. The mass size
was about like marble. The mass was not pain and bleed. Patient got
chemotherapy since 3 months ago (April 2016) three times but stop his
medication. The mass on his neck then spread to the chest and got bigger.
Patient continue his chemotherapy (July 18th 2016).
General status

Vital sign
• BP 90/60 mmHg
• HR 102 bpm
• RR 22 tpm
• T ax 36,3oC
• SpO2 98% without O2
 Physical diagnosis
• Head :simetric, normocephal, haematoma (-)
• Eye : Anemic conj. (+/+), icteric sclera (-/-)
Head • Mouth : Moist mucous membrane

General Status • Neck : increase of JVP (-), multiple mass on neck spread to chest.
Sized 20x30 cm, bleeding (+), ulcus (+)

• I : symmetric respiratory movement

• P : Symmetric VF
Chest • P : Sonor at all lung fields
• A : symmetric VBS, right = left, RH(-/-), WH (-/-)

• I : distension (-)
• A : Bowel sound normal
Abdomen • P : defence muscular (-) tenderness (-) mass (-)
• P : Tymphani (+)

Extremities • warm extremities (<), CRT < 2 sec,edema (-), parese (-)
Clinical Picture
Chest xray
CT Scan (March 31th 2016)

Lymphadenopathy colly level 4-5 kiri, suspect suppurative

lymphadenitis (tb?)
Laboratory
Examination Result Normal value
Hemoglobin 6.4 11.00-16.00 g/dl
Leukocyte 2.5 4.0-10.5 Thousand /ul
Erythrocyte 2.32 4.50-6.00 milion /ul
Hematocrite 20.0 42.00-52.00 Vol%
Platelets 68 150-450 Thousand /ul
Blood glucose 167 90-200 mg/dL
AST 35 0-46 U/I
ALT 18 0-45 U/I
Urea 18 10-50 Mg/dL
Creatinine 0.6 0.7-1.4 Mg/dL
 Working Diagnosis

Rhabdomyosarcoma at left colli + on

Chemotherapy + pansitopenia + Karnofsky
Score 50-60 %
Management
•VS Obs
•IVFD RL
•H2 blocker
•Inj. Tranexamic Acid
•Inj. Vit.K
•Dressing
•Complete blood count
•Blood Transfusion

•Co to Oncology:
•Hospitalized
3. Ch. Faisal Nurgusnaldi/ 14 y.o
1.21.85.92

Chief Complain:
Decreased of consciousness

History of Current Disease:

Since 6 hours before admission, patient got accident when he ride a bicycle
in Pengaron area he hit by a car from the left side then he felt to the right
side and his head hit the road. History of unconsciousness(+). History of
vomiting (+), history of bleeding from ear (-) nose (-) mouth (-). Because of
his complained patient was brought to Tanjung Hospital and then referred to
Ulin general hospital for further treatment.
Primary survey :
A : Clear without c-spine control
B : RR 20x/m, symmetrical shape
C : BP: 110/70 HR : 93x/m;
D : GCS 9 E2V2M5, pupil round equal Ø 3 mm, light reflex +/+
lateralization (-) , BH(-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal  2 hours before accident
E = Environtment  on the street
 Physical diagnosis
• Head :simetric, normocephal, haematoma (+) at right
temporooccipital Ø 7 cm
Head • Eye : Anemic conj. (-/-), icteric sclera (-/-)

General Status • Mouth : Moist mucous membrane

• Neck : increase of JVP (-)

• I : symmetric respiratory movement

• P : Symmetric VF
Chest • P : Sonorat all lung fields
• A : symmetric VBS, right = left, RH(-/-), WH (-/-)

• I : distension (-), bruises (-)

• A : Bowel sound normal
Abdomen • P : defence muscular (-) tenderness (-) mass (-)
• P : Tymphani (+)

Extremities • warm extremities (+), CRT < 2 sec,edema (-), parese (-)
Clinical Picture
Chest xray
CT Scan
CT Scan
Facial 3D
Laboratory
Examination Result Normal value
Hemoglobin 6.4 11.00-16.00 g/dl
Leukocyte 2.5 4.0-10.5 Thousand /ul
Erythrocyte 2.32 4.50-6.00 milion /ul
Hematocrite 20.0 42.00-52.00 Vol%
Platelets 68 150-450 Thousand /ul
Blood Glucose 167 90-200 mg/dL
AST 35 0-46 U/I
ALT 18 0-45 U/I
Urea 18 10-50 Mg/dL
Creatinine 0.6 0.7-1.4 Mg/dL
 Working Diagnosis

Moderate head injury + Closed Fracture Linear

at Right Temporooccipital + SDH at Right
temporal
 Management
•VS Obs
•O2
•Head up 30 deg
•IVFD NS
•Antibiotic
•Analgetic
•H2 blocker
•Complete blood count
•Head CT-scan
•Consult to neurosurgery
•Pro Craniotomy evacuation
•Patient Discharge by request
5. Mr. Galih/ 50 y.o
1.21.85.94

Chief Complain:
Pain at his backbone

History of Current Disease:

Since 4 days before admission, patient got accident when he repair the roof.
Patient felt from about ± 4 m in height with his back first. History of
unconsciousness (-). History of vomiting (+), history of bleeding from ear (-)
nose (-) mouth (-). After the accident patient felt pain on his backbone.
Numbness (-), cramp (-), weakness extremity (+). There was no complaint on
defecated and urinate. Patient also felt blurry vision after the accident.
Because of his complained patient brought to Grogot hospital, hospitalized
and then referred to Ulin general hospital for further treatment.
Primary survey :
A : Clear without c-spine control
B : RR 20x/m, symmetrical shape
C : BP: 140/90 HR : 86x/m;
D : GCS 15 E4V5M6, pupil round equal Ø 3 mm, light reflex +/+
lateralization (-) , BH(-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal  2 hours before accident
E = Environtment  on the house
 Physical diagnosis
• Head :simetric, normocephal, haematoma (-)
• Eye : Anemic conj. (-/-), icteric sclera (-/-), haematoma palpebra
Head (+/+), Visus OD 6/6, OS 6/6

General Status • Mouth : Moist mucous membrane

• Neck : increase of JVP (-)

• I : symmetric respiratory movement

• P : Symmetric VF
Chest • P : Sonorat all lung fields
• A : symmetric VBS, right = left, RH(-/-), WH (-/-)

• I : distension (-)
• A : Bowel sound normal
Abdomen • P : defence muscular (-) tenderness (-) mass (-)
• P : Tymphani (+)

Extremities • warm extremities (+), CRT < 2 sec,edema (-), parese (-)
• Local Status :
• Motoric status :
Superior : 5 II 5
Inferior : 5 II 5
• Sensoric status : + II +

DRE : normal sphyncter tone, smooth mucosa, rectal vault wasn’t collapse,
tenderness (-), mass (-), BCR (+), perineal reflex (+)
Gloves : feces (+), blood (-)
Clinical Picture
Chest Xray
Vertebrae Thoracal Xray
Vertebrae Thoracolumbal Xray
Laboratory
Examination Result Normal value
Hemoglobin 10.7 11.00-16.00 g/dl
Leukocyte 8.0 4.0-10.5 Thousand /ul
Erythrocyte 3.68 4.50-6.00 milion /ul
Hematocrite 33.2 42.00-52.00 Vol%
Platelets 183 150-450 Thousand /ul
Blood Glucose 122 90-200 mg/dL
AST 28 0-46 U/I
ALT 15 0-45 U/I
Urea 37 10-50 Mg/dL
Creatinine 0.9 0.7-1.4 Mg/dL
 Working Diagnosis

Mild head injury + close fr. of right zygoma +

SCI due to Compression Fracture of V. Th 9-10
without Neurolgical Deficit
Management
•VS Obs
•IVFD NS
•Analgetic
•H2 blocker
•Complete blood count
Thoracolumbo-sacral xray
•Consult to orthopedic
•TLSO
•Consult to plastic surgery:
•Conservative
6. Mrs. Sukinem/ 47 y.o
1.21.85.99

Chief Complain:
Decrease of unconsciousness

History of Current Disease:

Since 2 days before admission, while patient get activity in her house.
Patient suddenly felt. History of headache (+), history of vomiting (-), history
of hypertension (+), diabetes mellitus (-), stroke before (-). History of
weakness on extremity (-), spoken unclear (-). After the accident patient
brought to Sampit hospital and performed head CT Scan and then referred to
Ulin general hospital for further treatment.
General status

GCS
• E4V3M5 : 12

Vital sign
• BP 170/110 mmHg
• PR 90 bpm
• RR 24 tpm
• T ax 36,5oC
• SpO2 99% with O2 2 lpm nasal canule
 Physical diagnosis

• Head :simetric, normocephal, haematoma (-)

• Eye : Anemic conj. (-/-), icteric sclera (-/-)
Head • Mouth : Moist mucous membrane, parese N. VII (-)
General Status • Neck : increase of JVP (-)

• I : symmetric respiratory movement

• P : Symmetric VF
Chest • P : Sonorat all lung fields
• A : symmetric VBS, right = left, RH(-/-), WH (-/-)

• I : distension (-)
• A : Bowel sound normal
Abdomen • P : defence muscular (-) tenderness (-) mass (-)
• P : Tymphani (+)

• warm extremities (+), CRT < 2 sec,edema (-), hemiparese (+)

Extremities with motorix status sup: 2 II 5, inf : 2 II 5
Clinical Picture
Head CT Scan
Laboratory
Examination Result Normal value
Hemoglobin 13.8 11.00-16.00 g/dl
Leukocyte 7.6 4.0-10.5 Thousand /ul
Erythrocyte 4.45 4.50-6.00 milion /ul
Hematocrite 42.5 42.00-52.00 Vol%
Platelets 144 150-450 Thousand /ul
BG 142 90-200 mg/dL
AST 25 0-46 U/I
ALT 24 0-45 U/I
Urea 26 10-50 Mg/dL
Creatinine 0.8 0.7-1.4 Mg/dL
PT 8.5 9.9 – 13.5 Second
APTT 22.3 22.2-37 Second
INR 0.75
Cholesterol 301 158=220 mg/dl
 Working Diagnosis

Right hemiparese due to SH + ICH at left

temporal
Management
•VS Obs
•O2
•Head up 30 deg
•IVFD NS
•Antibiotic
•Analgetic
•H2 blocker
•Complete blood count
Head CTScan
•Consult to neurosurgery
•Craniotomy Evacuation