Emergency Report

th
January 10-11 2017
Chief on duty :
Shana Yusie Anwar
Coass on duty:
Ellsa Anggun K, Fachrul S Hadad, Adli Taufiq,
Nandita Putri A, Desy Puspita, M Dede R, Elma
R, Ayu E Tetta, Yulianti Ikhri Zul, M Hendy
Saputra, Tony Saputra, Nova Octavianty, Emma
Rahmadania, Felicia Arum
Minor Surgery : 3

Digestive Surgery : 2

Thorax Cardiovascular Surgery : -

Plastic Surgery : 1

Urology Surgery : 1
Neuro Surgery : -

Pediatric Surgery : -

Oncology Surgery : -

Orthopaedy : 1

Total : 8
No Identity Admission to ER Diagnose Treatment

1. Mrs. Magdalena/ 46y.o January, 10th Mild Head Injury IVFD NS

2017 13.05 WITA + Analgetic
Nasal Fracture Antibiotic
H2 Blocker
Antifibrinolytic

-Co To Neuro
surgery :
Konservatif ,
Hospitalized

-Co To Plastic
surgery :
-Hospitalized
No Identity Admission to ER Diagnose Treatment

2. Mr. Rudy Alpiansyah /32 January, 10th Acute Appendicitis -IVFD NS

y.o 2017 15.08 WITA + -Analgetic
hemoroid grade I -H2 Blocker

Co to Digestive
surgery :
-Laparoscopic
appendectomy
CITO
No Identity Admission to ER Diagnose Treatment

3. Tn. Syahrani/ 45 yo January, 10th urine retention ec urethra Antibiotic

2017 16.30 WITa rupture Antipyretics
H2 Blocker

Co. Urology Surgery

:
-Suprapubic
Cystostomy
-hospitalized
pro Bipolar voiding
Uretro Cystografi
No Identity Admission to ER Diagnose Treatment

4. Mrs. Husnul R/21yo January, 10th Blunt trauma at right Discarge by request
2017 20.01 WITa shoulder
No Identity Admission to ER Diagnose Treatment

5. Mrs. Siti Nuranisa/17 yo January, 10th Vulnus Excoriatum a/r Wound Care
2017 20.45 WITA dorsum pedis Obs 2 jam
Antibiotic zalp
Po. H2 Bloker
Antibiotic

Discharge by
permission
No Identity Admission to ER Diagnose Treatment

6. Mrs. Kurniawati /36yo January, 10th Vulnus ekscoriatum at right Wound Care
2017 20.45 WITa genu dextra Obs 2 jam
+ Antibiotic salp
Vulnus ekscoriatum at
Po. H2 Bloker
soulder dextra
Antibiotic

Discharge by
permission
No Identity Admission to ER Diagnose Treatment

7. Mr. Syarifudin/49 yo/ January, 10th Fracture hand thumb IVFD NS

2017 23.15 WITa sinistra+ rupture tendon Antibiotic
hand thumb sinistra Analgetic
H2 Bloker
ATS

Co. To Orthopedy
Surgery :
Fasting jam 07.00
Op. 16.00
No Identity Admission to ER Diagnose Treatment

8. Mr. Muchtari/74 yo/ January, 11th Susp. Ca Caput Pancreas dd Venflon

2017 01.20 WITa cholangio Cek Darah Lengkap
+
BSK
Co. to digestiv
+
Post TURP BPH surgery :
No answer yet

Patient discharge by
request
1. Mrs. Magdalena/46 th/1-23-54-79

Chief Complain:
Headache
History of Current Disease:
since 15 minutes before admission, post traffic accident.
Headache occurred continously.mechanisme of trauma is
unknown. she’s back of the head hit the stone. Helmed (-).
History of unconsciousness (+), history of seizure (-), history of
vomiting (+) contains food and blood, history of nausea(+),
history of bleeding from ear, nose and mouth (-/+/+). Patients
also complain about sharp wound at upper lip, bleeding active
(+),crepitasi (-).Patient brought to Ulin General Hospital by
civiliant.
Primary survey :
A : Clear, without c-spine control
B : RR 21 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP: 180/120 mmhg HR : 120x/m;
D : GCS 14 (E3V5M6) pupil round isokor Ø 3mm/3 mm, light reflex +/+
BH(-/-) BS(-) BO(-/-) BR (+/+)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before accident
E = Environment  on the street
Vital sign : Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and
• BP: 180/120movement
mmhg
symmetrical breathing sound
• Hr: 120 x/m C : BP:130/70 mmhg HR : 104x/m;
• RR: 21 x/m D : GCS 15, pupil round Ø 6mm/3 mm,
light reflex +/+
• T 36,7 0C BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before
accident
E = Environment  on the street
 Physical Examination
• Head :simetric, normocephal
• Eye : Anaemic conj. (-/-), icteric sclera (-/-)
Head • Nose : deformity (+) swelling (+) Floating (+) Bleeding (+/+) Krepitasi (-) Flattening (+)
• Mouth : Moist mucous membrane,

• I : Symmetric respiratory movement, no retraction

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

• I : distension (-) wound (-) hematoma(-) wound sutured (-)

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

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

•Maksilofascial :

At Rima orbita D/S : deformity (-/-) swelling (-/-)

At Maxilla D/S : deformity (-/-) swelling (-/-)
At Zygoma D/S : deformity (-/-) swelling (-/-)
At Mandibula D/S : deformity (-/-) swelling (-/-) Maloklusi (-)
At Nasal : deformity (+) swelling (+) Floating (+) Bleeding (+/+)
Krepitasi (-) Flattening (+)
Clinical picture
Thorax X-Ray
Skull X-Ray
3 D fascial
Ct-Scan
Examination Result Normal value
hemoglobin 13.8 11.00-16.00 g/dl

Leucosit 10.0 4.0-10.5 Thousand /ul

eritrosit 4.53 4.50-6.00 milion /ul

hematocrit 41.3 42.00-52.00 Vol%

trombocit 181 150-450 Thousand /ul

Random Blood Glucose 186 <200 Mg/dL

SGOT 48 0-46 U/I

SGPT 44 0-45 U/I

Urea 27 10-50 Mg/dL

Creatinine 1.1 0.7-1.4 Mg/dL

Working Diagnosis

Mild Head Injury GCS 15

+
Nasal Fracture
Management
• Analgetic
• Antibiotic
• H2 Blocker
• Antifibrinolytic

• Co To Neuro surgery :
Konservatif , Hospitalized
• Co To Plastic surgery :
• -Hospitalized
2.Mr. Rudi Alpiansari/32 yo/1-23-74-64

Chief Complain:
Abdominal pain
History of Current Disease:
since 3 days before admission. The pain occurred at the lower
right regio, suddenly and intermittent. Patient had the same
complaint since 6 months ago. History of neusea (+) vomiting
(+) >3x, loss of appetite (+) since 3 days ago. Patient
hospitalized at marabahan hospital before and out of
treatment by his own request 2 days ago. Last taking analgetic
medication 2 days ago. Urinate and defecation are normal.
History of trauma (-) hemorroid (+)
Vital sign : Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and
• movement
BP 110/70 mmgh
symmetrical breathing sound
• Hr 98 Bpm C : BP:130/70 mmhg HR : 104x/m;
• RR 21 tpm D : GCS 15, pupil round Ø 6mm/3 mm,
light reflex +/+
• T 36,5 0C BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before
accident
E = Environment  on the street
 Physical Examination
• Head :simetric, normocephal
Head • Eye : Anaemic conj. (-/-), icteric sclera (-/-)
• Mouth : Moist mucous membrane,

• I : Symmetric respiratory movement, no retraction

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

• I : distension (-)
• A : Bowel sound normal
Abdomen • P : defence muscular (-), rebound tendernes (+), tendernes (+),
rovsing sign (-) blumberg sign (-)
• P : Tymphani (+)

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

Rectal Toucher
TSA (+)
mass (+) six o’clock pulsed (+), chewy consistency,
Blood (-) feces (+) like a bean
Avarado Score : 4
Examination Result Normal value
hemoglobin 15.3 11.00-16.00 g/dl
Leucosit 6.0 4.0-10.5 Thousand /ul
eritrosit 4.83 4.50-6.00 milion /ul
hematocrit 45.3 42.00-52.00 Vol%
trombocit 219 150-450 Thousand /ul
Random Blood Glucose 120 <200 Mg/dL

SGOT 29 0-46 U/I

SGPT 27 0-45 U/I
Urea 26 10-50 Mg/dL
Creatinine 1.1 0.7-1.4 Mg/dL
PT 10,6 9,9-13,5 Second
APTT 23,4 22.2-37,0 Second
Na 138,4 135-146 Mmol/L
K 3,8 3,4-5,4 Mmol/L
Cl 109 95-100 Mmol/L
Examination Result Normal value
PT 10,6 9,9-13,5 Second
APTT 23,4 22.2-37,0 Second
Na 138,4 135-146 Mmol/L
K 3,8 3,4-5,4 Mmol/L
Cl 109 95-100 Mmol/L
Thorax X Ray
Clinical picture
Working Diagnosis

Apendicitis acute (Avarado Score : 4 )

+
hemoroid grade I
Management
• IVFD NS
• Analgetic
• H2 Blocker

• Co to Digestive surgery :
• -Laparoscopic appendectomy CITO
3. Tn. Syahrani/ 45 yo

Chief Complain:
Pain at Genital
History of Current Disease:
Patient referred from Marabahan Hospital with diagnosis rupture
urethra with main complaint pain at genitalia since 28 hours
before admission. Before the main complaint occurred, patient
sliped and hitted the scrotum with wood bean. After that,
patient felt pain at his scrotum and lower regio of the
abdominal. Patient also complaint couldn’t defecate and
urinate. History of nausea (-) vomiting (-) bloody urine (+) and
fever (-)
History of past disease –
History of family disease -
Vital sign : Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and
• movement
BP 110/70 mmhg
symmetrical breathing sound
• Hr 98 Bpm C : BP:130/70 mmhg HR : 104x/m;
• RR 20 tpm D : GCS 15, pupil round Ø 6mm/3 mm,
light reflex +/+
• T 36,5 0C BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before
accident
E = Environment  on the street
 Physical Examination
• Head :simetric, normocephal
Head • Eye : Anaemic conj. (-/-), icteric sclera (-/-)
• Mouth : Moist mucous membrane,

• I : Symmetric respiratory movement, no retraction

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

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

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

Suprapubic
L: distension (+)
F: Tenderness (+), Solid, undulasi (+)

Genital (Scrotum)
L: Hematoma (+), abrasion (+), swelling (+)
F: Tenderness (+)

Rectal Tousea
TSA (+), Floating Prostat (+), feses (+),blood(-)
Clinical picture
Pelvic X-Ray
Pelvic X-Ray
Examination Result Normal value
hemoglobin 13.3 11.00-16.00 g/dl

Leucosit 16.7 4.0-10.5 Thousand /ul

eritrosit 4.44 4.50-6.00 milion /ul

hematocrit 39.9 42.00-52.00 Vol%

trombocit 206 150-450 Thousand /ul

Random Blood Glucose 109 <200 Mg/dL

SGOT 50 0-46 U/I

SGPT 48 0-45 U/I

Urea 35 10-50 Mg/dL

Creatinine 0.9 0.7-1.4 Mg/dL

Working Diagnosis

1. Clinical diagnose : genital pain

2. Etiology diagnose : urethra rupture
3. Complication diagnose : Urine retention
4. Other diagnose : -
Management
•Antibiotic
•Antipyretics
•H2 Blocker

•Co. Urology Surgery :

•-Suprapubic Cystostomy
•-hospitalized
•pro Bipolar Foiding Uretro Cystografi
4.Mrs. Husnul R/21yo/1-23-74-80

Chief Complain:
Pain of shoulder
History of Current Disease:
Patient post traffic accident since 10 minutes before admission.
Patient fell to the right side with position hand hitted the
ground first while riding a motorcycle. History of
unconsciusness (-), headache (-) nausea (-) vomiting (-) seizure
(-) ear (-) nose (-) bleeding (-)
Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP: 120/80 mmhg HR : 90x/m;
D : GCS 14 (E3V5M6) pupil round isokor Ø 3mm/3 mm, light reflex +/+
BH(-/-) BS(-) BO(-/-) BR (+/+)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before accident
E = Environment  on the street
Vital sign : Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and
• movement
BP: 120/80 mmhg
symmetrical breathing sound
• Hr: 90 x/m C : BP:130/70 mmhg HR : 104x/m;
• RR: 20 x/m D : GCS 15, pupil round Ø 6mm/3 mm,
light reflex +/+
• T 36,7 0C BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before
accident
E = Environment  on the street
 Physical Examination
• Head :simetric, normocephal
• Eye : Anaemic conj. (-/-), icteric sclera (-/-)
Head • Nose : deformity (-) swelling (-) Floating (-) Bleeding (-/-) Krepitasi (-) Flattening (-)
• Mouth : Moist mucous membrane,

• I : Symmetric respiratory movement, no retraction

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

• I : distension (-) wound (-) hematoma(-) wound sutured (-)

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

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

Clinical picture
Working Diagnosis

Blunt trauma at right shoulder

Management

Discharge by request
5.Mrs. Siti Nuranisa/17 yo

Chief Complain:
pain
History of Current Disease:
Patient post traffic accident since 15 minutes before admission.
Patient hitted from her back side while riding a motorcycle and
fell to left hit the asphalt. Patient also complaint headache.
History og unconsciusness (-) headache (+) nausea (-) vomiting
(-) seizure (-) bleeding of ear/nose/mouth (-/-/-)
Primary survey :
A : Clear, without c-spine control
B : RR 21 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP: 110/70 mmhg HR : 80x/m;
D : GCS 14 (E3V5M6) pupil round isokor Ø 3mm/3 mm, light reflex +/+
BH(-/-) BS(-) BO(-/-) BR (+/+)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before accident
E = Environment  on the street
Vital sign : Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and
• movement
BP: 110/70 mmhg
symmetrical breathing sound
• Hr: 80 x/m C : BP:130/70 mmhg HR : 104x/m;
• RR: 21 x/m D : GCS 15, pupil round Ø 6mm/3 mm,
light reflex +/+
• T 36,7 0C BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before
accident
E = Environment  on the street
 Physical Examination
• Head :simetric, normocephal
• Eye : Anaemic conj. (-/-), icteric sclera (-/-)
Head • Nose : deformity (-) swelling (-) Floating (-) Bleeding (-/-) Krepitasi (-) Flattening (-)
• Mouth : Moist mucous membrane,

• I : Symmetric respiratory movement, no retraction

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

• I : distension (-) wound (-) hematoma(-) wound sutured (-)

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

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

Clinical picture
Working Diagnosis

Vulnus Excoriatum a/r dorsum pedis

Management

•Obs 2 jam
•Wound Care
•Antibiotic zalp
•Po. H2 Bloker
•Antibiotic

•Discharge by Permission
6.Mrs. Kurniawati/36 yo

Chief Complain:
pain
History of Current Disease:
Patient post traffic accident since 15 minutes before admission.
Patient hitted from her back side while riding a motorcycle and
fell to left hit the asphalt. Patient also complaint headache.
History og unconsciusness (-) headache (+) nausea (-) vomiting
(-) seizure (-) bleeding of ear/nose/mouth (-/-/-)
Primary survey :
A : Clear, without c-spine control
B : RR 21 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP: 120/70 mmhg HR : 89x/m;
D : GCS 14 (E3V5M6) pupil round isokor Ø 3mm/3 mm, light reflex +/+
BH(-/-) BS(-) BO(-/-) BR (+/+)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before accident
E = Environment  on the street
Vital sign : Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and
• movement
BP: 120/70 mmhg
symmetrical breathing sound
• Hr: 89 x/m C : BP:130/70 mmhg HR : 104x/m;
• RR: 21 x/m D : GCS 15, pupil round Ø 6mm/3 mm,
light reflex +/+
• T 36,7 0C BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before
accident
E = Environment  on the street
 Physical Examination
• Head :simetric, normocephal
• Eye : Anaemic conj. (-/-), icteric sclera (-/-)
Head • Nose : deformity (-) swelling (-) Floating (-) Bleeding (-/-) Krepitasi (-)
Flattening (-)
• Mouth : Moist mucous membrane,

• I : Symmetric respiratory movement, no retraction

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

• I : distension (-) wound (-) hematoma(-) wound sutured (-)

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

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

Clinical picture

At regio right shoulder dextra

Working Diagnosis

Vulnus ekscoriatum at right genu dextra

+
Vulnus ekscoriatum at soulder dextra
Management
•Obs 2 jam
•Wound Care
•Antibiotic zalp
•Po. H2 Bloker
•Antibiotic

•Discharge by permission
7.Mr. Syarifudin/49 yo /1-23-74-84

Chief Complain:
pain
History of Current Disease:
Patient brought to the hospital with main complaint pain at his
left thumb since 30 minutes before admission. Patient strucked
by grindstone while making a cleaver. Patient also complaint
difficult to move his tumb
Vital sign : Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and
• movement
BP: 130/80 mmhg
symmetrical breathing sound
• Hr: 89 x/m C : BP:130/70 mmhg HR : 104x/m;
• RR: 21 x/m D : GCS 15, pupil round Ø 6mm/3 mm,
light reflex +/+
• T 36,7 0C BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before
accident
E = Environment  on the street
 Physical Examination
• Head :simetric, normocephal
• Eye : Anaemic conj. (-/-), icteric sclera (-/-)
Head • Nose : deformity (-) swelling (-) Floating (-) Bleeding (-/-) Krepitasi (-) Flattening (-)
• Mouth : Moist mucous membrane,

• I : Symmetric respiratory movement, no retraction

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

• I : distension (-) wound (-) hematoma(-) wound sutured (-)

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

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

Ar thumb manus sinistra

L : deformity (+) swelling (+) bleeding (-)

F : Tenderness (+) CRT >2’, distal sense
M : ROM limited due to pain
Clinical picture
X-Ray Manus
lab
Examination Result Normal value
hemoglobin 13.2 11.00-16.00 g/dl

Leucosit 11.2 4.0-10.5 Thousand /ul

eritrosit 4.36 4.50-6.00 milion /ul

hematocrit 38.6 42.00-52.00 Vol%

trombocit 249 150-450 Thousand /ul

Working Diagnosis

Fracture hand thumb sinistra+ rupture tendon hand

thumb sinistra
Management
•IVFD NS
•Antibiotic
•Analgetic
•H2 Bloker
•ATS

•Co. To Orthopedy Surgery :

•Fasting jam 07.00
•Op. 16.00
8. Mr. Muchtari/ 74 y.o/1-03-53-57

Chief Complain:
Icteric
History of Current Disease:
Patient brought to the hospital with main complaint icteric
since 2 week before admission. Patient complaint that his
stool and urine is yellow enamelled. Patient also complaint
often loss of appetite since a half month ago and nausea
since one month ago. Patient had been doing various health
checks and then referred to the hospital because there is
pancreas.
History of past disese : HT (-) DM (-) Post op BPH one week
ago
Vital sign : Primary survey :
A : Clear, without c-spine control
B : RR 20 x/m, symmetrical shape and
• movement
BP 130/80 mmhg
symmetrical breathing sound
• Hr 70 Bpm C : BP:130/70 mmhg HR : 104x/m;
• RR 18 tpm D : GCS 15, pupil round Ø 6mm/3 mm,
light reflex +/+
• T 36,8 0C BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal  2 hour before
accident
E = Environment  on the street
 Physical Examination
• Head :simetric, normocephal
Head • Eye : Anaemic (-/-), icteric sclera (+/+)
• Mouth : Moist mucous membrane,

• I : Symmetric respiratory movement, no retraction

• P : Symmetric VF
Chest • P : Sonor at all lung fields
• A : symmetric VBS, no rhonchi , no wheezing
• Heart: Gallop

• I : distension (+) wound (-) hematoma(-)

• A : Bowel sound normal
Abdomen • P : defence muscular (-) minimal tenderness (-) mass (-), asites (+)
• P : dull (+)

Extremities • warm extremities , edema (-), parese (-) ikterik (+)

RT : TSA strong, ampulla uncolapse, mass (-)

Handscoen : Blood (-) feces (-)

Clinical picture
Ct-Scan 30-12-2016
• Pancreatic head tumor dengan extrahepatal cholestasis pelebaran
pancreatic duct
• Left renal stone, multiple bladder stone.
Examination Result Normal value

hemoglobin 10.2 11.00-16.00 g/dl

Leucosit 13.6 4.0-10.5 Thousand /ul
eritrosit 3.11 4.50-6.00 milion /ul
hematocrit 29.7 42.00-52.00 Vol%
trombocit 399 150-450 Thousand /ul
Random Blood Glucose 117 <200 Mg/dL

SGOT 195 0-46 U/I

SGPT 222 0-45 U/I
Urea 48 10-50 Mg/dL
Creatinine 0.7 0.7-1.4 Mg/dL
Bilirubin total 29,4 0.20 – 1.20 Mg/dl
Bilirubin direct 14,28 0.00 – 0.40 Mg/dl
Bilirubin indirect 15,16 0.20- 0.60 Mg/dL
CEA : 3.71 ng/ml
Ca 19-9 : 484.5 U/ml
Working Diagnosis
Ca Caput Pancreas dd cholangio
+
BSK
+
Post TURP BPH
Management
•Venflont

•Co to Digestive surgery :

Not answer yet

Patient discharge by request

TERIMAKASIH