REPORT

January, 6th 2016

Agustian Deny

O Inpatient

: 3 patient
O Outpatient : 1 patient
O Total
: 4 patients

Outpatient
O Mr. F, male, 16 yo. VE e/r Collar e.c

rope kites. WT. Anti

Analgetic, Antibiotic.

tetanus,

Features

1. Colic Ureter

Primary Survey
O Airway : Clear
O Breathing : Clear, rate: 20x/min
O Circulation : Clear, pulse rate:

78x/min, regular, BP: 110/70 mmHg

O Disability: Alert

Secondary survey

Identity
O Name: Mr. A
O Age

: 18 years old
O Religion : Islam
O Address : Student

Chief Complaint
Left abdominal pain

Present Illness
Pstient complaint of Left abdominal pain for 2 days
before admission, the paint was first felt in flank region
and radiates to left abdomen, the pain was constant.
Patient also complains pain at the end of urination for
one week before admission, urination was difficult 3
days before admission, sand (-), blood (-), muddy (-)
Defecate and flatus (-) since 2 days before admission,
the last at Sunday in evening, hard (-), brown (+)
Nausea (-), vomiting (-)

Vital Sign
O Conciussness : Compos Mentis, GCS

15
O Pulse
: 78 x / minute
O Respiratory Rate : 20 x / minute
O BP
: 110/70
O Temperature : 36,8 OC

Physical Examinations
General Status
O Head : Normocephal
O Eyes : CA (-/-), SI (-)
O ENT : in normal range
O Neck : tenderness (+) illiaca sinistra
O Chest : symmetrical
O Cor

: S1, S2 M (-) G (-)

O Pulmo : VBS (+/+), Wh (-/-), Rh (-/-)

O Abdomen

o Inspection
: flat
o Auscultation: Bowel sound (+) normal, metalic

sound (-),
o Percution : timpani (+)
o Palpation : Soepel, tenderness (+) iliaca sinistra.
Epigastrium, muscular defense (-), CVA (-/+),
ballotement (-/-)
O Extremity

(-)

: warm (+), CRT < 2 seconds, edema

Localis status
- Tenderness (+) iiliaca
sinistra.
-- CVA (-/+)
-- ballotement (-/-)

O RT: ampula recti good, tonus good,

mucosa smooth, handscoon: feses

(+) blood (-)

Working Diagnosis
O Colic ureter e.c susp. Urolithiasis

sinistra
O Constipation

Additional Examination
O Complete Blood Count (Leucocyte

14,6 x 109/l, Eritrocyte 5,58 x 1012/l ,

Hgb 16,7 g/dl, Trombocyte 91 x 109/l)
O Blood Glucose : 87 mg/dl
O Ureum: 56 mg/dl
O Creatinin: 1,5 mg/dl
O SGOT: 19 u/l
O SGPT: 21 u/l

X-Ray BNO
O Impression:
O Opaque concrament (-)
O Air distribution in bowel seems normal
O Vertebral alignment normal,
osteophyte (-)

USG

Diagnosis
O Colic ureter e.c susp. Urolithiasis

sinistra
O Constipation
O Observasi trombositopenia

Treatment
O Medicamentosa
O IVFD RL 20 tpm
O Cefotaxime 3 x 2 gr (IV)
O Ketorolac 3 x 30 mg (IV)
O Opilax 3 x C II

2. Colic Abdomen

Primary Survey
O Airway : Clear
O Breathing : Clear, rate: 24x/min
O Circulation : Clear, pulse rate:

84x/min, regular, BP: 150/90 mmHg

O Disability: Alert

Secondary
Survey

Identity
O Name: Mr. S
O Age

: 36 years old
O Religion : Islam
O Address : Self employee

Chief Complaint
Left abdominal pain

Present Illness
Left abdominal pain for 1 day before
admission, persistent pain, nausea (+),
vomiting (+), vomiting more than 5 times
Fever (-), heartburn (-), Urinate (+) N,
Defecate (+) N, Flatus (-) since last night.

Vital Sign
O Concioussness : Compos Mentis, GCS 15
O Pulse

: 84 x / minute
O BP
: 150/90 mmHg
O Respiratory Rate : 24 x / minute
O Temperature : 36 OC

Physical Examinations
General Status
O Head : Normocephal
O Eyes : CA (-/-), SI (-)
O ENT : in normal range
O Neck : No complain
O Chest : symmetrical
O Cor

: S1, S2 M (-) G (-)

O Pulmo : VBS (+/+), Wh (-/-), Rh (-/-)

O Abdomen

o Inspection
: flat
o Auscultation: Bowel sound (+) increased, metalic

sound (-),
o Percution : timpani (+)
o Palpation : Soepel, tenderness (+) epigastrium et
lumbal sinistra. Epigastrium, muscular defense (-),
CVA (-/+), ballotement (-/-)

O Extremity

(-)

: warm (+), CRT < 2 seconds, edema

Localis Status
Tenderness
(+)
lumbar sinistra.
-- CVA (-/-)
-- ballotement (-/-)

Working Diagnosis
O Colic ureter dextra

Additional Examination
O Complete Blood Count (Leucocyte

15,8 x 109/l, Eritrocyte 5,17 x 1012/l ,

Hgb 16,1 g/dl, Trombocyte 202 x
109/l)
O Blood Glucose : 126 mg/dl
O Uric acid : 4,94 mg/dl
O Ureum: 32 mg/dl
O Creatinin: 0,9 mg/dl

BNO X-Ray
O Impression :
O Opaque concrament (-)
O Air distribution in bowel seems normal
O Vertebral alignment normal,

osteophyte (-)

Diagnosis
O Colic ureter dextra

Treatment
O Medicamentosa
O IVFD RL 20 tpm
O Ceftriaxone 1 x 2 gr (IV)
O Ketorolac 3 x 30 mg (IV)
O Ranitidin 2 x 1 (IV)

Mild head injury

- Open fracture comminuted

phalang medial digiti V

Primary Survey
O Airway

: Clear
O Breathing : Spontan, 20x/minute
O Circulation : BP: / mmHg, Pulse: 98
x/minute, CRT < 2
O Disability
: Alert
O Event : Hit by a car when driving
motorcyle

Secondary Survey
O Allergy

: (-)
O Medication : (-)
O Past Illness : Asthma (-), DM (-), HT
(-)
O Last meal : 11.00 am
O Event : Hit by a car when driving
motorcyle.

Anamnesis
O Patient complaint of open wound in

left foot and her fifth finger post

traffic
accident.
patient
also
complaining about swelling and pain
in head. Patient was fainted right
after the incident and the Patient
was unable to recall the incident.
Neusea (-), vomitting (-).

Examination Head to
Toe
O Head : Normocephal, injury (+), pain (-)
O Eyes: Pupil isochor 3mm/3mm, Light Reflex (+/+)
O ENT : Bleeding (-)
O Neck : Injury (-), Pain (-)
O Chest: Pain (-), Dispnea (-)
O Cor : S1,S2 regular, M(-), G(-)
O Pulmo : VBS (+/+), Wh (-/-), Rh (-/-)

O Abdomen : Soepel, tenderness (-), Bowel sound (+)

N.
O Hepar and Lien: Normal

O Extremity: vulnus laceratum e/r dorsum pedis

sinistra, multiple vulnus excoriatum

Local Status: Left Foot

O Look

: vulnus laceratum e/r digiti

minimi dorsum pedis sinistra, base:
bone, active bleeding (+), deformity
(+)
O Feel : swollen (-), tenderness (+),
CRT <2, Sensory (+)
O Move : -

O Local Status: Multiple Vulnus

Excoriatum and hematom e/r

Frontalis

Working diagnosis
O Mild head injury
O Open frakture e/r digiti V pedis

sinistra grade IIIb

Additional Examination
O Complete Blood Count (Leucocyte

14,6 x 109/l, Eritrocyte 5,58 x 1012/l ,

Hgb 16,7 g/dl, Trombocyte 91 x 109/l)
O Blood Glucose : 87 mg/dl
O Ureum: 56 mg/dl
O Creatinin: 1,5 mg/dl
O SGOT: 19 u/l
O SGPT: 21 u/l

X-Ray: AP/Lateral of Pedis

Dextra

Diagnosis
O Mild head injury
O Open fracture comminuted phalang

proximal digiti V pedis sinistra

O Closed
fracture
comminuted
metatarsal digiti IV pedis sinistra

Treatment
O Wound Toilet
O Anti Tetanus Serum injection
O Bioxon 1 x 2 gr
O Ketorolac 3 x 30 mg
O Pre. Operation

THANK YOU