MR 20-12-14

Emergency Case Report
2014, 20-21TH December
Resident on Duty : dr. Yan Aditya

Chief Co-Assistant : Erina
Team :
Endah, Mira, Firdha, Dyah, Bimo, Ady
Minor Surgery
:-
Digestive Surgery
:1
Thorax Cardiovascular Surgery
:-
Plastic Surgery
:-
Urology Surgery
:-
Neurosurgery
:5
Pediatric Surgery
:-
Oncology Surgery
:1
Orthopaedy
:3
Total
: 10
No
Identity
Mr. Anang Rusdi/

63 y.o/ 1.13.25.81
Admission to
E.R.
Diagnosis
Treatment / Planning
20th
December
2014/ 15.00
Bloody feces due to rectal

tumor
T 2 N1 M0
Complete Blood Count

IVFD RL 20 tpm
Patient discharge by permission and
control as outpatient
No
Identity
Mr. Hendri/ 20
y.o/1.13.25.87
Admission
to E.R.
20th
December
2014/ 16.15
Diagnosis
Closed fracture tibia

sinistra
X-ray antebrachii sinistra AP+LAT

Patient discharge by request
No
Identity
Admission
to E.R.
Mrs. Sarimas/
56
y.o/1.13.25.88
20th
December
2014/18.00
Diagnosis
CT Scan Head Trauma + Facial 3D +
Bone Window
X-ray antebrachii dextra, femur dextra,
cruris dextra
IVFD RL 20 tpm
H2 Blocker
Analgesic
Antibiotic
Folley catheter
No
Identity
Admission
to E.R.
Ch. M. Azhar/
14 y.o/ 0-60-6918
20th
December
2014/ 18.40
Diagnosis
Mild Head Injury
Complete Blood count
X-ray trauma series
IVFD RL 20 tpm
H2 blocker
Analgesic
No
Identity
Mr. Kadir/ 25
y.o/ 1-13-25-91
Admission
to E.R.
Diagnosis
Mild Head Injury + susp.

20th
December Fracture Basis cranii fossa
media
2014/ 18.45
CT Scan Head
IVFD NaCl 0,9% 20 tpm
O2 4 lpm
Head up
Antibiotic
H2 blocker
Analgesic
No
Identity
Admission
to E.R.
Mrs. Arbayah/
52 y.o/
1.13.25.90
20th
December
2014/ 17.15
Diagnosis
X-ray Cruris dextra & Shoulder dextra
IVFD RL 20 tpm
Analgesic
Arm sling
No
Identity
Mr. Sabli/ 35
y.o/ 0.72.54.13
Admission
to E.R.
20th
December
2014/ 20.30
Diagnosis
Hernia Inguinalis Lateralis Obs. vital sign

Sinistra Inkarserata
Complete blood count
IVFD RL 20 tpm
Antbiotic
Analgesic
H2 blocker
Consult to Digestive surgeon
department:
Pro cito herniotomy
No
Identity
Mr. Yusran/ 35
y.o/ 1.13.25.99
Admission
to E.R.
20th
December
2014/ 22.00
Diagnosis
Mild Head Injury +
CT Scan Head
O2 4 lpm nasal canul
Folley catheter
IVFD NaCl 2000cc/24 hours
Antibiotic
Analgesic
H2 blocker
No
Identity
Ms. Norliani/ 17
y.o/ 1.13.25.95
Admission
to E.R.
20th
December
2014/ 20.45
Diagnosis
X-ray skull AP+LAT
Primary suture
No
Identity
10
Mr. Zaini/ 20
y.o/ 1.13.26.06
Admission
to E.R.
Diagnosis
21th
December
2014/ 01.20
Mild Head Injury +

Fracture radius ulna
dextra
CT Scan Head
Folley catheter
IVFD RL 20 tpm
Antibiotic
Analgesic
H2 blocker
1. Mr. Anang Rusdi/ 63 y.o/ 1.13.25.81

20th December 2014/ 15.00
Chief Complain : Bloody feces
History: Patient complain his bloody feces since 3 months ago.
Bloody feces come intermittent and there was much blood.
Patient also feel pain when defecation. Patient work as painter.
Patient said that he lost his weight gradually and become thin
since a year ago.
Vital Sign
BP : 120/80 mmHg
PR : 87 bpm
RR : 19 tpm
T : 36,9oC
General Status
Head/Neck
Eyes : anemic conjunctiva, (-) icteric sclera (-)

Mouth : Wet mucous
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
Chest
I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-), no wheezing
Abdomen
Extremities
I : Wound (-), distension (-), hematoma (-)

A : Bowel sound (+)
P : Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-)
P : Tymphani
Warm extremities
Clinical Picture
Local Status
I : mass about 4 cm,
blood (+), pus (+)
P : consistency kenyal,
mobile
Laboratorium Result (20-12-2014)

Examination
Result
Normal value
hemoglobin
12.8
14.00-18.00
g/dl
Leucosit
8.8
4.0-10.5
Ribu/ul
eritrosit
4.22
4.50-6.00
juta/ul
hematocrit
37.4
42.00-52.00
Vol%
trombocit
521
150-450
Ribu/ul
RDW-CV
14.5
11.5-14.7
MCV
88.8
80.0-97.0
Fl
MCH
30.3
27.0-32.0
Pg
MCHC
34.2
32.0-38.0
Gran%
80.4
50.0-70.0
Limfosit%
14.3
25.0-40.0
MID%
5.3
3.0-9.0
Examination
Result
Normal value
Gran#
7.10
2.50-7.00
Ribu/ul
Limfosit#
1.3
1.25-4.0
Ribu/ul
MID#
0.4
Random Blood
Glucose
98
<200
Mg/dL
SGOT
32
0-46
U/I
SGPT
20
0-45
U/I
Urea
26
10-50
Mg/dL
Creatinine
0.9
0.7-1.4
Mg/dL
Ribu/ul
Working Diagnosis
Bloody feces due to Rectal tumor
T2N1M0
Management
IVFD RL 20 tpm
Patient discharge by permission and control
as outpatient
2. Mr. Hendri/ 20 y.o/ 1.13.25.87

Chief Complain : Pain at left hand
History: 30 minutes before admission, patient had
an accident. Patient was riding motorbike and hit

other vehicle from other side. Then patient fell to
the left side and hit his left hand.
Primary Survey
A
Clear
Clear, RR= 20 bpm, symmetric

respiratory movement, symmetric
VBS
BP : 110/70 mmHg
Pulse rate :89 bpm, strong, reguler,
CRT < 2 sec.
GCS E4V5M6, round and equal

pupils diameter (3mm/3mm), light
reflexes (+/+), no paralysis
2 hours before
admission
On the road
Secondary Survey
Head/Neck
Chest
Abdomen
Extremities
Eyes : anemic conjunctiva, (-) icteric sclera (-),

Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
I : Wound (-), distension (-), hematoma (-)
A : Bowel sound (+)
P : Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-)
P : Tymphani
Warm extremities
Clinical Picture
Local Status
Swelling(+),
deformity(+)
Pain (+), crepitation (+)
ROM limited due to
pain
X-ray antebrachii sinistra
Planning Diagnose
Closed fracture tibia sinistra
Management
X-ray antebrachii sinistra AP+LAT
IVFD RL 20 tpm
Patient discharge by request
3. Mrs. Sarimas/ 56 y.o/1.13.25.88

Chief Complain : Decreased consciousness
History: 6 hours before admission, patient had an accident.
Patient was hit by motorcycle. Patient complain that her right
hand and leg pain and unable to move. Patient was treated at
Puskesmas Sembabani and got IVFD RL. Then she brought
directly to Ulin hospital for further treatment.
Primary Survey
A
Clear, Snoring (-), gurgling (-),

VBS, Rh (-/-) wh (-/-)
BP : 100/60 mmHg
Pulse rate : 74 bpm, reguler, strong
lifted, CRT >2 sec.

pupils diameter (3mm/3m), light
IVFD RL
1 hours before
admission
Road
Secondary survey
Head/Neck
Chest
Head : multiple sutured wound

Eye : Anemic conj. (-/-), icteric sclera (-/-)
Mouth : wet mucous
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)
I : Symmetric respiratory movement, retraction (-),

multiple vulnus escoriation (+)
P : Symmetric VF
P : Sonor in all lung field
A : Symmetric VBS, Rh (-/-), Wh (-/-)
Abdomen
I : Wound (-), distension (-)

A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).
P : Tympanic in all quadrants
Extremities
Warm extremities
Clinical Picture
Local Status
a/r cruris sinistra
L: swelling (+),
deformity (+)
F: pain (+), crepitation
(+)
M: ROM limited due to
pain
Local Status
a/r antebrachii dextra
L: swelling (+),
deformity (+)
(+)
pain
Local Status
a/r head:
L: sutured wound (+),
swelling (+)
F: pain (+)
CT Scan Head Trauma + Facial 3D +

Bone Window
X-ray Antebrachii dextra AP+LAT
X-ray femur dextra AP+LAT
X-ray cruris dextra AP+LAT

Examination
Result
Normal value
hemoglobin
10.1
14.00-18.00
g/dl
Leucosit
8.9
4.0-10.5
Ribu/ul
eritrosit
3.45
4.50-6.00
juta/ul
hematocrit
30.5
42.00-52.00
Vol%
trombocit
187
150-450
Ribu/ul
RDW-CV
14.1
11.5-14.7
MCV
88.6
80.0-97.0
Fl
MCH
29.2
27.0-32.0
Pg
MCHC
33.1
32.0-38.0
Gran%
81.0
50.0-70.0
Limfosit%
15.3
25.0-40.0
MID%
3.7
3.0-9.0
Examination
Result
Normal value
Gran#
7.20
2.50-7.00
Ribu/ul
Limfosit#
1.4
1.25-4.0
Ribu/ul
MID#
0.3
PT Result
12.5
9.9-13.5
INR
1.09
Control Normal
PT
11.4
APTT Result
19.0
22.2-37.0
Detik
Control Normal
APTT
26.1
Random Blood
Glucose
185
<200
Mg/dL
SGOT
59
0-46
U/I
SGPT
38
0-45
U/I
Urea
32
10-50
Mg/dL
Creatinine
0.8
0.7-1.4
Mg/dL
Ribu/ul
Detik
Working Diagnosis
Management
CT Scan Head Trauma + Facial 3D + Bone Window

X-ray antebrachii dextra, femur dextra, cruris dextra
IVFD RL 20 tpm
H2 Blocker
Analgesic
Antibiotic
Folley catheter
4. Ch. M. Azhar/ 14 y.o/ 0-60-69-18

Chief Complain :
History: 20 minutes before admission, patient had an accident
at Kuripan. Patient admit that he hit person when across the
road. When patient try to avoid that person, he fell from his
motorcycle. His mouth got blunt trauma. Patient use helmet
when riding. History of unconscious (-), vomit (-), blood from
mouth/nose/ear (+/+/-).
Primary Survey
A

VBS, Rh (-/-) wh (-/-)
BP : 110/60 mmHg
lifted, CRT >2 sec.

1 hours before
admission
Road
Secondary survey
Mouth : wet mucous
enlargement (-/-)
Head/Neck
Chest
I : Symmetric respiratory movement, retraction (-)

P : Symmetric VF
Abdomen
I : Wound (-), distension (-), vulnus escoriation (-)

Extremities
Warm extremities
Clinical Picture
X-ray Skull AP+LAT
X-ray Cervical AP+LAT
X-ray Thorax AP
X-ray Pelvis

Examination
Result
Normal value
hemoglobin
13.5
14.00-18.00
g/dl
Leucosit
19.7
4.0-10.5
Ribu/ul
eritrosit
5.91
4.50-6.00
juta/ul
hematocrit
40.8
42.00-52.00
Vol%
trombocit
279
150-450
Ribu/ul
RDW-CV
15.1
11.5-14.7
MCV
69.2
80.0-97.0
Fl
MCH
22.8
27.0-32.0
Pg
MCHC
33.0
32.0-38.0
Gran%
84.2
50.0-70.0
Limfosit%
8.7
25.0-40.0
MID%
7.1
3.0-9.0
Examination
Result
Normal value
Gran#
16.60
2.50-7.00
Ribu/ul
Limfosit#
1.7
1.25-4.0
Ribu/ul
MID#
1.4
PT Result
11.3
9.9-13.5
INR
0.99
Control Normal
PT
11.4
APTT Result
21.9
22.2-37.0
Detik
Control Normal
APTT
26.1
Random Blood
Glucose
131
<200
Mg/dL
SGOT
23
0-46
U/I
SGPT
13
0-45
U/I
Urea
24
10-50
Mg/dL
Creatinine
1.0
0.7-1.4
Mg/dL
Ribu/ul
Detik
Working Diagnosis
Mild Head Injury
Management
X-ray trauma series

IVFD RL 20 tpm
H2 blocker
Analgesic
5. Mr. Kadir/ 25 y.o/ 1-13-25-91

Chief Complain : Bleeding from left ear
History: One hour before admission, patient had an accident
when he was riding motorcycle. Helmet (+). In Kayutangi he
was hit by another motorcycle, he fell and his head hit the
ground. History of unconsciousness (-), history of vomiting (+),
history of bleeding from ear (+), nose (+), mouth (-). He was
brought by civilian to Ulin general hospital.
Primary Survey
A

VBS, Rh (-/-) wh (-/-)
BP : 120/90 mmHg
lifted, CRT >2 sec.

3 hours before
admission
On the road
Secondary survey
Vulnus escorea e/r supra orbita sinistra 1 cm
Vulnus escorea e/r zygoma dextra 3 cm
Vulnus escorea e/r 10x2 cm
Ear : otthorea (+)
Mouth : wet mucous
enlargement (-/-)
Head/Neck
Chest

P : Symmetric VF
Abdomen

Extremities
Warm extremities
e/r antebrachii dextra: vulnus escorea 2 x 5 cm
e/r genu sinistra vulnus escorea multiple
e/r digiti 345 pedis sinistra: vulnus escorea multiple
Clinical Picture
Local Status
a/r head
Vulnus escoriatum(+)
Local Status
a/r ear
L: blood (+)

Examination
Result
Normal value
hemoglobin
14.8
14.00-18.00
g/dl
Leucosit
10.4
4.0-10.5
Ribu/ul
eritrosit
5.49
4.50-6.00
juta/ul
hematocrit
43.9
42.00-52.00
Vol%
trombocit
217
150-450
Ribu/ul
RDW-CV
15.0
11.5-14.7
MCV
80.0
80.0-97.0
Fl
MCH
26.9
27.0-32.0
Pg
MCHC
33.7
32.0-38.0
Gran%
78.5
50.0-70.0
Limfosit%
15.2
25.0-40.0
MID%
6.3
3.0-9.0
CT Scan Head
Examination
Result
Normal value
Gran#
8.20
2.50-7.00
Ribu/ul
Limfosit#
1.6
1.25-4.0
Ribu/ul
MID#
0.6
PT Result
9.5
9.9-13.5
INR
0.84
Control Normal
PT
11.4
APTT Result
21.7
22.2-37.0
Detik
Control Normal
APTT
26.1
Random Blood
Glucose
130
<200
Mg/dL
SGOT
41
0-46
U/I
SGPT
21
0-45
U/I
Urea
21
10-50
Mg/dL
Creatinine
0.9
0.7-1.4
Mg/dL
Ribu/ul
Detik
Working Diagnosis
Mild Head Injury + susp. Fracture Basis cranii fossa media
Management
CT Scan Head
IVFD NaCl 0,9% 20 tpm
O2 4 lpm
Head up
Antibiotic
H2 blocker
Analgesic
6. Mrs. Arbayah/ 52 y.o/ 1.13.25.90

Chief Complain :
History:
Primary Survey
A

VBS, Rh (-/-) wh (-/-)
BP : 120/90 mmHg
lifted, CRT >2 sec.

IVFD RL 20 tpm, Inj.

Ketorolac 30 mg
4 hours before
admission
On the road
Secondary survey
Mouth : wet mucous
enlargement (-/-)
Head/Neck
Chest

P : Symmetric VF
Abdomen

Extremities
Warm extremities
Clinical Picture
Local Status
a/r cruris dextra
L: swelling (+), open
wound (-)
(+)
pain
Local Status
a/r clavicula dextra
L: swelling (-)
(+)
painS
X-ray cruris dextra
X-ray clavicula dextra
Working Diagnosis
Fraktur tibia fibula + clavicula dextra
Management
X-ray Cruris dextra & Shoulder dextra
IVFD RL 20 tpm
Analgesic
Arm sling
Posterior slab
After Posterior slab & Arm sling
7. Mr. Sabli/ 35 y.o/ 0.72.54.13

Chief Complain : Lumph in groin
History: 4 hours before admission to hospital, patient complain
about lumph in groin that cant get in. The lumph was appear
since 5 months ago but never stay. The lumph can get bigger
and swollen by itself. The lumph get bigger when he work so
hard or lift something weight. Patient work as labour.
Vital Sign
BP : 120/80 mmHg
PR : 72 bpm
RR : 18 tpm
T : 36,7oC
General Status
Mouth : wet mucous
enlargement (-/-)
Head/Neck
Chest

P : Symmetric VF
Abdomen

Extremities
Warm extremities
Clinical Picture
Local Status
a/r inguinal et scrotalis
sinistra
Mass 10 cm
Bowel sound (+)
Rectal Toucher
TSA strong
Ampulla isnt collapse

Mass (-)
NT (-)
Mukosa licin
Feces (+), blood (-)

Examination
Result
Normal value
hemoglobin
10.1
14.00-18.00
g/dl
Leucosit
20.8
4.0-10.5
Ribu/ul
eritrosit
4.02
4.50-6.00
juta/ul
hematocrit
30.9
42.00-52.00
Vol%
trombocit
351
150-450
Ribu/ul
RDW-CV
15.4
11.5-14.7
MCV
77.1
80.0-97.0
Fl
MCH
25.1
27.0-32.0
Pg
MCHC
32.6
32.0-38.0
Gran%
82.2
50.0-70.0
Limfosit%
10.5
25.0-40.0
MID%
7.3
3.0-9.0
Examination
Result
Normal value
Gran#
17.10
2.50-7.00
Ribu/ul
Limfosit#
2.2
1.25-4.0
Ribu/ul
MID#
1.5
PT Result
12.5
9.9-13.5
INR
1.09
Control Normal
PT
11.4
APTT Result
22.5
22.2-37.0
Detik
Control Normal
APTT
26.1
Random Blood
Glucose
200
<200
Mg/dL
SGOT
43
0-46
U/I
SGPT
43
0-45
U/I
Urea
21
10-50
Mg/dL
Creatinine
1.1
0.7-1.4
Mg/dL
Ribu/ul
Detik
Working Diagnosis
Hernia Inguinalis Lateralis Sinistra Inkarserata
Management
Obs. vital sign

IVFD RL 20 tpm
Antbiotic
Analgesic
H2 blocker
Consult to Digestive surgeon department:
Pro cito herniotomy
8. Mr. Yusran/ 32 y.o/ 1.13.25.99

Chief Complain : Pain in face
History: 5 hours before admission patient had an accident.
Mechanism of trauma was unknown. Patient was brought by
police officer to Ratu Zalecha hospital. History of
unconsciousness (-), history of vomiting (-), history of bleeding
from mouth/ear/nose (+/+/+). Patient then refer to Ulin hospital
for further treatment.
Primary Survey
A

VBS, Rh (-/-) wh (-/-)
BP : 120/90 mmHg
lifted, CRT >2 sec.

IVFD NaCl 20 tpm +

tramadol, Inj.
Ketorolac 30 mg, Inj.
Kalnex, Inj. Piracetam,
Inj. Ranitidin, Inj.
ceftriaxone
2 hours before
admission
On the road
Secondary survey
Disk face (+)
L: Open wound a/r supra orbita dextra 5 x 1 cm.
based on bone
F: crepitation (+)
Mouth : wet mucous
enlargement (-/-)
Head/Neck
Chest

P : Symmetric VF
Abdomen
I : Wound (-), distension (-), vulnus escoriation (-),

jejas (+)
Extremities
Warm extremities
Clinical Picture
CT Scan Head
X-ray cruris sinistra

Examination
Result
Normal value
hemoglobin
15.1
14.00-18.00
g/dl
Leucosit
21.9
4.0-10.5
Ribu/ul
eritrosit
4.86
4.50-6.00
juta/ul
hematocrit
43.6
42.00-52.00
Vol%
trombocit
229
150-450
Ribu/ul
RDW-CV
14.8
11.5-14.7
MCV
89.8
80.0-97.0
Fl
MCH
31.0
27.0-32.0
Pg
MCHC
34.6
32.0-38.0
Gran%
85.1
50.0-70.0
Limfosit%
8.0
25.0-40.0
MID%
6.9
3.0-9.0
Examination
Result
Normal value
Gran#
18.60
2.50-7.00
Ribu/ul
Limfosit#
1.8
1.25-4.0
Ribu/ul
MID#
1.5
PT Result
11.4
9.9-13.5
INR
1.00
Control Normal
PT
11.4
APTT Result
23.2
22.2-37.0
Detik
Control Normal
APTT
26.1
Random Blood
Glucose
154
<200
Mg/dL
SGOT
269
0-46
U/I
SGPT
163
0-45
U/I
Urea
37
10-50
Mg/dL
Creatinine
1.5
0.7-1.4
Mg/dL
Ribu/ul
Detik
Working Diagnosis
Mild Head Injury + fracture ??
Management
CT Scan Head
X-ray cruris sinistra
O2 4 lpm nasal canul
Folley catheter
IVFD NaCl 2000cc/24 hours

Antibiotic
Analgesic
H2 blocker
9. Ms. Norliani/ 17 y.o/ 1.13.25.95

Chief Complain :
History: Post KLLD
Primary Survey
A

VBS, Rh (-/-) wh (-/-)
BP : 120/90 mmHg
lifted, CRT >2 sec.

IVFD RL 20 tpm, Inj.

Ketorolac 30 mg
4 hours before
admission
On the road
Secondary survey
Mouth : wet mucous
enlargement (-/-)
Head/Neck
Chest

P : Symmetric VF
Abdomen

Extremities
Warm extremities
Clinical Picture
Local Status
a/r parietal
X-ray Skull AP+LAT

Examination
Result
Normal value
hemoglobin
13.3
14.00-18.00
g/dl
Leucosit
15.2
4.0-10.5
Ribu/ul
eritrosit
4.76
4.50-6.00
juta/ul
hematocrit
40.1
42.00-52.00
Vol%
trombocit
186
150-450
Ribu/ul
RDW-CV
12.7
11.5-14.7
MCV
84.4
80.0-97.0
Fl
MCH
27.9
27.0-32.0
Pg
MCHC
33.1
32.0-38.0
Gran%
80.3
50.0-70.0
Limfosit%
12.3
25.0-40.0
MID%
7.4
3.0-9.0
Examination
Result
Normal value
Gran#
12.20
2.50-7.00
Ribu/ul
Limfosit#
1.9
1.25-4.0
Ribu/ul
MID#
1.1
PT Result
9.0
9.9-13.5
INR
0.80
Control Normal
PT
11.4
APTT Result
19.6
22.2-37.0
Detik
Control Normal
APTT
26.1
SGOT
31
0-46
U/I
SGPT
22
0-45
U/I
Urea
17
10-50
Mg/dL
Creatinine
0.6
0.7-1.4
Mg/dL
Ribu/ul
Detik
Working Diagnosis
Mild Head Injury
Management
X-ray skull AP+LAT

Primary suture
10. Mr. Zaini/ 20 y.o/ 1.13.26.06

Chief Complain : Bleeding from nose
History: 6 hours before admission, patient had an accident.
Patient had an open wound on head and fracture of right hand.
History of unconsciousness (-), history of vomiting (-), bleeding
from nose (+).
Primary Survey
A

VBS, Rh (-/-) wh (-/-)
BP : 110/70 mmHg
lifted, CRT >2 sec.

IVFD RL, Inj. Ketorolac

30 mg, Inj. Cefotaxime,
Inj. ranitidin
6 hours before
admission
On the road
Secondary survey
Mouth : wet mucous
enlargement (-/-)
Head/Neck
Chest

P : Symmetric VF
Abdomen

Extremities
Warm extremities
Clinical Picture
Local status
a/r frontal
Local Status
a/r antebrachii dextra
L: swelling (+),
deformity (+)
(+)
pain
X-ray Thorax AP
X-ray skull AP+LAT
X-ray cruris dextra
CT Scan Head
Working Diagnosis
Mild Head Injury + Fracture radius ulna dextra
Management
CT Scan Head
Folley catheter
IVFD RL 20 tpm
Antibiotic
Analgesic
H2 blocker
THANK YOU

MR 20-12-14

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

MR 20-12-14

Enviado por

Direitos autorais:

Formatos disponíveis

Emergency Case Report

2014, 20-21TH December

Resident on Duty : dr. Yan Aditya

Thorax Cardiovascular Surgery

Mr. Anang Rusdi/

Bloody feces due to rectal

Complete Blood Count

Closed fracture tibia

X-ray antebrachii sinistra AP+LAT

Mild Head Injury + susp.

Hernia Inguinalis Lateralis Obs. vital sign

Mild Head Injury +

1. Mr. Anang Rusdi/ 63 y.o/ 1.13.25.81

Eyes : anemic conjunctiva, (-) icteric sclera (-)

I : Symmetric respiratory movement, no retraction

I : Wound (-), distension (-), hematoma (-)

Laboratorium Result (20-12-2014)

2. Mr. Hendri/ 20 y.o/ 1.13.25.87

History: 30 minutes before admission, patient had

an accident. Patient was riding motorbike and hit

Clear, RR= 20 bpm, symmetric

GCS E4V5M6, round and equal

Eyes : anemic conjunctiva, (-) icteric sclera (-),

I : Symmetric respiratory movement, no retraction

X-ray antebrachii sinistra

3. Mrs. Sarimas/ 56 y.o/1.13.25.88

Clear, Snoring (-), gurgling (-),

Clear, RR= 24 bpm, symmetric

GCS E4V4M6, round and equal

Head : multiple sutured wound

I : Symmetric respiratory movement, retraction (-),

I : Wound (-), distension (-)

CT Scan Head Trauma + Facial 3D +

X-ray Antebrachii dextra AP+LAT

X-ray femur dextra AP+LAT

X-ray cruris dextra AP+LAT

Laboratorium Result (20-12-2014)

CT Scan Head Trauma + Facial 3D + Bone Window

4. Ch. M. Azhar/ 14 y.o/ 0-60-69-18

Clear, Snoring (-), gurgling (-),

Clear, RR= 24 bpm, symmetric

GCS E4V5M6, round and equal

I : Symmetric respiratory movement, retraction (-)

I : Wound (-), distension (-), vulnus escoriation (-)

X-ray Skull AP+LAT

X-ray Cervical AP+LAT

Laboratorium Result (20-12-2014)

X-ray trauma series

5. Mr. Kadir/ 25 y.o/ 1-13-25-91

Clear, Snoring (-), gurgling (-),

Clear, RR= 22 bpm, symmetric

GCS E3V5M5, round and equal

I : Symmetric respiratory movement, retraction (-)

I : Wound (-), distension (-), vulnus escoriation (-)

Laboratorium Result (20-12-2014)

6. Mrs. Arbayah/ 52 y.o/ 1.13.25.90

Clear, Snoring (-), gurgling (-),

Clear, RR= 22 bpm, symmetric

GCS E3V5M5, round and equal

IVFD RL 20 tpm, Inj.

I : Symmetric respiratory movement, retraction (-)

I : Wound (-), distension (-), vulnus escoriation (-)

X-ray cruris dextra

X-ray clavicula dextra