Emergency Report

March 8th 9th 2017

Chief on Duty:
Fachrul Setiawan Hadad

Coass On Duty:
Shana Yusie, Ellsa Anggun,
Adly, Risa, Mutia, Tommy,
Ahmad, Deriel, Miftah, Zuwita,
General Surgery : -

Digestive Surgery : 1

Thorax Cardiovascular Surgery : 1

Plastic Surgery : -

Urology Surgery : -

Neuro Surgery : 3

Pediatric Surgery : -

Oncology Surgery : 2

Orthopaedy : -

Total : 7
 Patient List
No Identity Admission to ER Diagnose Treatment

1 Mr. Slamet/57 y.o. March 8th 2017 Post op mini O2 Non-Rebreathing Mask
5.10 pm laparotomy + IVFD Aminofluid
install drainage Analgetic
Antbiotic
w/I peritonitis ec
H2 Blocker
gaster Inotropic
perforation dd
perforation of
hollow viscus Co. To Digestive Surgery:
POD IV+ Septic Hospitallized ICU
shock
 Patient List
No Identity Admission to ER Diagnose Treatment

2 Mr. Milkie/21 y.o. March 8th 2017 Mild Head Injury Head up 30 degree
5.23 pm with GCS 10 O2 Nasal canul 3 lpm
(E3V2M5) + IVFD NS
Subgaleal Analgetic
hematoma Antibiotic
a/r occipital H2 Blocker
sinistra +
linier fracture Co. to Neuro Surgery:
of Hospitalized
temporoparie
tal bone
sinistra +
Hospitalized
Acquired
Pneumonia +
acute
psychotic
state dd
Skizofrenia
 Patient List
No Identity Admission to ER Diagnose Treatment

3 Mrs. Mulatinah/36 March 8th 2017 Benign Phyloides IVFD RL

y.o. 9.38 pm Tumor recidif of Analgetic
right breast + Antiemetic
anemia H2 blocker

Co. to Oncology surgery:

Transfusion PRC until Hb>10 mg/dl
Hospitalized
 Patient List
No Identity Admission to ER Diagnose Treatment

4 Mrs. Salhah/ 46 March 8th 2017 Ca Tongue IVFD RL

y.o 10.20 pm Squamous Cell Neutropic drip
Carsinoma Type on Antiemetic
Chemotherapy
Co. To Oncology Surgery:
Patient discharge by permission
 Patient List
No Identity Admission to ER Diagnose Treatment

5 Mrs. Rohilah/ March 8th 2017 Moderate Head Head up 30 degree

44 y.o 22.40 pm Injury GCS 12 O2 Nasal Canul 3 LPM
(E3V4M5) + ICH IVFD NS
a/r parietal Analgetic
dextra + H2 blockers
Hypertension Antibiotic
Grade I + DM
Type II controlled Co. to neurosurgery:
Hospitalized
 Patient List
No Identity Admission to ER Diagnose Treatment

6 Mr. Pramadita/ March 8th 2017 Mild Head Injury Wound toilet
29 y.o 3.30 am with GCS 15 + IVFD NS
Fracture oblique Analgetic
incomplete
costae VII Co to Thorax-Cardiovascular
posterior + Surgery:
Multiple vulnus Observation Vital sign and sign of
excoriatum hemato/pneumothorax (chest
pain/dypsnea)
 Patient List
No Identity Admission to ER Diagnose Treatment

7 Mr. Sunarko/ March 8th 2017 Severe head injury CT-Scan Head trauma
26 y.o/ 10.39 pm with GCS 7 Cervical and thoracal photo
(E1V2M4) + EDH IVFD NS
a/r Frontal dextra + Antibiotic
Fracture of os Analgetic
Frontal, orbita rime, H2 Blocker
zygoma, and
maxila dextra + Co. to Neuro Surgery:
multiple vulnus CT Scan head if Primary survey
excoriatum clear
Intubation

After there is a CT-Scan:

Pro CITO Craniotomy Evacuation

Co. to Plastic Surgery:

Conservative, Hospitalized and pro
ORIF Elective
 1. Mr. Slamet/57 y.o./5.10 pm

Chief complaint : bloated of stomach

History of current disease: (autoanamnesa)
Patient have chief complain bloated of stomach since 8 days before
admission. Patient complain, sometimes he felt bloated and sometimes he
doesnt since 2 weeks before admission but since 8 days ago the bloated
not disappear until now. Patient have complain nausea but there is no
vomiting. Pain at stomach (+) especially at middle regio of stomach.
Patient can fort and he can defecate normally. Fever (+) since 5 days
before admission contineusly. Patient has loss appetite after that and have
complain fatigue. After physical examination of doctor from RS Tanah
Bumbu patient suggested refer to RSUD Ulin but caused by his
Haemoglobin is low and his general condition patient must to do cito
laparotomy from general surgeon of RS Tanah Bumbu and after 4 days
Vital Sign
GCS: E4V5M6
Heart Rate: 86 beat per minutes
Blood Pressure: 120/80mmHg with drip of NE 0,05 meQ
T: 36,8
RR: 44 times per minutes
SpO2: 96% with Non-Rebreathing Mask
Physical examination
Eye : anemic (+/+), icteric (-/-)
Nose : deviation (-/-) NGT (+) production 50cc/8 hours, green
Head - Neck Mouth : dry (-)
Neck : Lesion (-)

I: Simmetry respiratory movement, retraction (-), Central Venous Catheter

installed at regio thorax dextra
Thorax Pal: simetrical fremitus vokal
Per: Sonor
Aus: Rh -/-, Wh -/- bruit (-)

I: distension (+) verban (+) drainage (+) with spooling 20 tear per minutes
at regio umbilical
Abdomen Aus: Bowel sound (+) 6 times/minutes
Pal: mass (-) tenderness (+) at regio umbilical and epigastric
Per: tympani

The extremities warm, pale (-/-) sianosis (-/-)

Extremities Edema (-/-)
Clinical Picture
At regio thorax dextra
I: Simmetry respiratory movement, retraction (-), Central Venous Ca
installed at regio thorax dextra
Pal: simetrical fremitus vokal
Per: Sonor
Aus: Rh -/-, Wh -/- bruit (-)

At regio abdomen
I: distension (+) verban (+) drainage (+) with spooling 20 tear per m
at regio umbilical
Aus: Bowel sound (+) 6 times/minutes
Pal: mass (-) tenderness (+) at regio umbilical and epigastric
Per: tympani
BNO 3 position (Pre op)

Left lateral decubitus:

Free air at upper side of LLD

BNO 3 position (Pre op) supine and semi-
erect
Laboratory 8-03-2017 (Ulin General Hospital)
Examination Result Normal value
Hemoglobin 9,9 11.00-16.00 g/dl
Leucocyte 17.5 4.65-10.3 103 /ul
Erythrocyte 4.11 4.00-5.50 106 /ul
Hematocrit 34.5 42.00-54.00 Vol%
Thrombocyte 228 150-356 103 /ul
MCV 73.1 75-96 f
MCH 21.1 28-32 pg
MCHC 28.6 33-37 %
Gran% 79.4 50-70 %
Limfosit% 9.1 25-40 %
MID% 10.5 4.0-11.0 %
Gran# 14.00 2.50-7.50 Ribu/ul
Limfosit# 1.6 1.25-4.0 Ribu/ul
MID# 1.9 Ribu/ul
Laboratory 8-03-2017 (Ulin General Hospital)
Examination Result Normal value
PT 11.5 11.00-16.00 second
APTT 31.2 22.5-37.0 second
INR 4.11 4.00-5.50 second
Random Glucose 94 <200 Mg/dl
SGOT 36 0-46 u/l
SGPT 29 0-45 U/l
Albumin 2.9 3.5-5.5 g/dl
Ureum 53 10-50 Mg/dl
Creatinine 1.0 0.7-1.4 Mg/dl
Na 139.3 135-146 Mmol/l
K 3.7 3.4-5.4 Mmol/l
Clorida 111.4 95-100 Mmol/l
Working Diagnose

Post op mini laparotomy + install

drainage w/I peritonitis ec gaster
perforation dd perforation of hollow
viscus POD IV+ Septic shock
Management
O2 Non-Rebreathing Mask
IVFD Aminofluid
Analgetic
Antbiotic
H2 Blocker
Inotropic

Co. To Digestive Surgery:

Hospitallized ICU
 2. Mr. Milkie/21 y.o./6.23 pm

Chief Complain:
Decrease of consciousness
History of Current Disease: (alloanamnese with his brother and
nurse of Kapuas Hospital
Patients refer from Kapuas Hospital with chief complain decrease of
consciousness since 3 days ago. Its come after he hitted by iron stick.
The patient is convicted of murder and the victim is his uncle with clurit.
After do a murder of uncle, patient try to kill his father but his father can
dodge his attack and then do counter attack with spear and hit the low
back of patient. After that patient run and arrested by pedestarian.
Patient attacked and got punch and iron stick at his head. After accident
patient unconsciousness. Vomiting (-) Bleeding from ear/mouth/nose
(+/-/-), seizure (-). Patient hospitalized at Kapuas Hospital with diagnose
Vital sign:
GCS: E3V2M5
Respiration rate: 29 times/minute
Heart rate: 108 times/minute
Temp: 37,2 degree celcius
Blood presure: 140/70 mmHg
SpO2: 97% with nasal kanul 3 LPM
 Physical examination
Head: Swelling (+) at regio occipital sinistra ec blunt trauma 4cmx2cmx1cm,
fluctuation (+)
Eye : anemic (-/-), icteric (-/-)
Head - Neck Nose : deviation (-/-)
Ear: dry blood (+/-)
Mouth : dry (-)
Neck : Lesion (-), retraction (-)

I: Symmetrical respiratory movement, Retraction Intercostal (-/-)

Thorax Pal: decrease of fremitus vocal

Per: dull
Aus: lower in pitch rhonki +/+ at all lungs regio, Wh -/-

I: distention (-)
Aus: Bowel sound motility (+)
Abdomen Pal: Tenderness (-) mass (-)
Per: Tymphani

Extremiti The extremities warm, pale (-/-) sianosis (-/-)

es
Edema (-/-)
 Clinical Picture

At regio occipital sinistra: Swelling (+) 4cmx2cmx1cm,

At regio auricularis sinistra:
fluctuation (+)
Active bleeding (-)
Laboratory 8-03-2017 (Ulin General Hospital)
Examination Result Normal value
Hemoglobin 10,7 11.00-16.00 g/dl
Leucocyte 11,0 4.65-10.3 103 /ul
Erythrocyte 3,88 4.00-5.50 106 /ul
Hematocrit 36,6 32.00-44.00 Vol%
Thrombocyte 169 150-356 103 /ul
MCV 94.5 75-96 f
MCH 27.5 28-32 pg
MCHC 29.2 33-37 %
Gran% 88.2 50-70 %
Limfosit% 8.4 25-40 %
MID% 3.4 4.0-11.0 %
Gran# 7.90 2.50-7.50 Ribu/ul
Limfosit# 0.8 1.25-4.0 Ribu/ul
MID# 0.3 Ribu/ul
Laboratory 8-3-2017 (RSUD Ulin)
Examination Result Normal value
Random Blood Glucose 104 <200 Mg/dl
SGOT 75 0-46 U/I
SGPT 38 0-45 U/I
Urea 55 10-50 Mg/dL
Creatinine 1.5 0.7-1.4 Mg/dL
Thorax X-Ray 8.3.2017 (ulin Hospital)

Cardio:
There is no abnormality

Lung:
Increase of haziness/infltration at all area of lungs
Suggest pneumonia
CT Scan head trauma
CT Scan
Head
Trauma
3D Facial
Working Diagnosis

Mild Head Injury with GCS 10 (E3V2M5) +

Subgaleal hematoma a/r occipital
sinistra + linier fracture of
temporoparietal bone sinistra +
Hospitalized Acquired Pneumonia +
acute psychotic state dd Skizofrenia
Management
Head up 30 degree
O2 Nasal canul 3 lpm
IVFD NS
Analgetic
Antibiotic
H2 Blocker

Co. to Neuro Surgery:

Hospitalized
 3. Mrs. Mulatinah/36 y.o./9.38 pm

Chief complaint : pain at right breast

History of current illness:
Patient brought to Ulin Hospital with chief complain pain
at right breast since 1 month before admission. Pain is
come after the bulge at her right breast is broken.
Bleeding (+) yellow wish fluid (+). The mass appear
since 1 years before admission. The size frst is like a
marble and grow bigger as big as tennis ball. Because
of there is no pain at the mass patient not control to
doctor. Now patient have complain nausea without
vomiting since 1 month and loss appetite. Patient have
complain fever since 4 days and decrease after
consumption antipiretic and increase again.
 History of past illness:
Patient have complain bulge at right breast since 2014
like a marble and 5 month later a bulge growth bigger
like a chickens egg at 9 oclock. Pain (-). Patient control
to doctor at Sampit Hospital and patient take operation
procedure of bulge (resection in June, 2014). From
biopsy result founded the mass is benign and caused by
there is no pain patient not control to doctor.
2015 the bulge is appear at 6 oclock of right breast
Primary survey:
Not perform primary survey caused by not patient
trauma

Vital sign:
Heart Rate: 86 beat per minutes
Blood Pressure: 120/80mmHg
T: 36,8
RR: 21 times per minutes
SpO2: 96%
Karnofsky Score: 70 (care for self; unable to carry on normal
activity to do active work)
 Physical
Examination
Head : simetric, normocephal, mass (-)
Eye : Anaemic conj. (-/-), icteric sclera (-/-), edem palpebra (-/-)
Head Mouth : Moist mucous membrane
Neck : Increasion level of JVP (-), enlargement lymph node (-)

I : symmetric respiratory movement, ulcus (+) at mamae dextra size

8x5x4cm active bleeding (-) pus (+)
Chest P : tenderness (+)
P : Sonor
A : symmetric VBS, no rhonchi, no wheezing

I : distension (-)
A : Bowel sound normal
Abdomen P : hepar/lien/mass unpalpable
P : Tymphani (+)

Extremities warm extremities, CRT < 2, edem (-)

Clinical Picture
Photos of past illness (2015) Photos of current illness

a/r mamae dextra

I: ulcus (+) size 8x5x4cm active bleeding (-) pus (+)
P: Tenderness (+)
Biopsy
23/6/14
Laboratory 8-03-2017 (Ulin General Hospital)
Examination Result Normal value
Hemoglobin 8,6 11.00-16.00 g/dl
Leucocyte 11,4 4.65-10.3 103 /ul
Erythrocyte 3.32 4.00-5.50 106 /ul
Hematocrit 28,9 32.00-44.00 Vol%
Thrombocyte 406 150-356 103 /ul
MCV 87.3 75-96 f
MCH 25.9 28-32 pg
MCHC 29.7 33-37 %
Gran% 77.2 50-70 %
Limfosit% 15.6 25-40 %
MID% 7.2 4.0-11.0 %
Gran# 8.80 2.50-7.50 Ribu/ul
Limfosit# 1.8 1.25-4.0 Ribu/ul
MID# 0.8 Ribu/ul
Working Diagnosis

Benign Phyloides Tumor recidif of

right breast + anemia
Management
IVFD RL
Analgetic
Antiemetic
H2 blocker

Co. to Oncology surgery:

Transfusion PRC until Hb>10 mg/dl
Hospitalized
 4. Mrs. Salhah/ 46 y.o /9.20 pm

Chief Complain:
Fatigue
History of Current Disease:
Patient brought to the hospital with complain fatigue since 2 days
before admission. Before that she had a frst chemotherapy procedure
at Ulin Hospital caused by her disease. Patient has cant eat because
her disease and also losing her appetite. Nausea (-) vomiting (-)
headache (-)

History of Past Illness:

Bulge at tongue since 2 months before admission the frst size like a
marble and growth bigger as big as grapes. The bulge is solid and
Primary survey:
Not perform primary survey caused by not patient
trauma

Vital sign:
Heart Rate: 93 beat per minutes
Blood Pressure: 130/80mmHg
T: 37,3
RR: 22 times per minutes
SpO2: 97%
Karnofsky Score: 80 (normal activity with effort, some signs or
symptoms of disease)
 Physical
Examination
Head : simetric, normocephal, mass (-)
Eye : Anaemic conj. (-/-), icteric sclera (-/-)
Mouth : Moist mucous membrane
Head Tongue: at right side Nodule size 3x1x05cm, irreguler, asimetric, pain (+) and at
middle of tongue 0,5x,0,5cm irregular and asimetric, pain (+)
Neck : Increasion level of JVP (-), enlargement lymph node (-)

I : symmetric respiratory movement, retraction (-) lesion (-)

P : symmetric VF
Chest P : Sonor at all lung felds
A : symmetric VBS, no rhonchi, no wheezing

I : distension (-) lesion (-)

A : Bowel sound normal
Abdomen P : Mass (-) tenderness (-)
P :Tymphani

Extremities warm extremities, CRT < 2

Clinical Picture
Local Status:
Ins:
at right side Nodule size 3x1x05cm, irregular, asimetric
at middle of tongue 0,5x,0,5cm irregular and asimetric

Pal: tenderness (+)

Biopsy (23/2/17
Protocol
of Chemotherapy
Laboratory 8-03-2017 (Ulin General Hospital)
Examination Result Normal value
Hemoglobin 12,6 11.00-16.00 g/dl
Leucocyte 6,4 4.65-10.3 103 /ul
Erythrocyte 4.45 4.00-5.50 106 /ul
Hematocrit 41,6 32.00-44.00 Vol%
Thrombocyte 220 150-356 103 /ul
MCV 93.7 75-96 f
MCH 28.3 28-32 pg
MCHC 30.2 33-37 %
Gran% 75.2 50-70 %
Limfosit% 20.5 25-40 %
MID% 4.3 4.0-11.0 %
Gran# 4.80 2.50-7.50 Ribu/ul
Limfosit# 1.3 1.25-4.0 Ribu/ul
MID# 0.3 Ribu/ul
Working Diagnosis

Ca Tongue Squamous Cell Carsinoma

Type on Chemotherapy
Management
IVFD RL
Neutropic drip
Antiemetic

Co. To Oncology Surgery:

Patient discharge by permission
 5. Mrs. Rohilah/ 44th y.o /22.45 pm

Chief Complain:
Decrease of Consciousness
History of Current Disease: (Alloanamnese with her husband)
Patient was referred by RSUD H. Andi Abduchrahman Noor Tanah Bumbu
with chief complain Decrease of consciousness since 3 days before
admission after the patient fall from motorcycle with a mechanism
patients clothes was hooked by the gear of motorcycle and her left head
hit the ground and than she was founded by her husband with faint,
helmet (+) but not lock correctly, vomiting (+) 3 times, seizure (-),
bleeding from her nose, mouth and ear was negative. There is scretch at
her both hand and both leg active bleeding (-). After the accident patient
brought to Tanah Bumbus Hospital and hospitalized for 3 days
History of past illness:
Primary survey:
A : clear, without c-spine control
B : RR 20 x/m, regular with nasal canul 3 lpm, Rh (-/-), Wh (-/-)
C : HR : 78 x/m, regular, strong, BP: 150/90mmHg
D : GCS 12: E3V4M5, pupil isokor, round 4mm/4mm, direct and indirect light
reflex +/+, Lateralization (-/+)

Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 4 hours before
E = Environment on the street
 Physical
Examination
Head : simetric, crepitation (-) Vulnus laceratum a/r eyelids and zygoma
sinistra(sutured)
Head Eye : Anemic conj. (-/-), hematoma palpebra superior (-/+)
Mouth : Moist mucous membrane
Neck :Increasion level of JVP (-) lacerated (-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
Chest P : Sonor at all lung felds
A : symmetric VBS, lower in pitch rhonchi at all regio of lungs , no
wheezing

I : distension (-) wound (-) hematoma(-) bruise (-)

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

warm extremities, CRT 2, multiple vulnus excoriatum a/r antebrachii

Extremities d et s + a/r genue d et s
Neurological examination
GCS: E3V4M5
Pupil: Isikor, round 4mm/4mm direct and indirect light reflex +/+
Doll eye movement (+/+)
Lateralization (-/+)
Pathological Reflex: babinski (-/-)
Clinical Picture
Local status:
Hematom a/r Palpebra superior dextra
Vulnus laceratum a/r eyelids and zygoma dextra (sutured)
Clinical Picture

Local status:
Vulnus excoriatum at regio ante brachii d et s
Clinical Picture
Local status:
Vulnus excoriatum at regio genue d et s
Head CT-Scan
(8-03-2017)
 Head CT-Scan
(8-03-2017)
ICH parietal dextra
volume 1.51 cc
3D Skull (8/3/2017)
Laboratory 8-03-2017 (Ulin General Hospital)
Examination Result Normal value
Hemoglobin 12,6 11.00-16.00 g/dl
Leucocyte 6,4 4.65-10.3 103 /ul
Erythrocyte 4.45 4.00-5.50 106 /ul
Hematocrit 41,6 32.00-44.00 Vol%
Thrombocyte 220 150-356 103 /ul
MCV 93.7 75-96 f
MCH 28.3 28-32 pg
MCHC 30.2 33-37 %
Gran% 75.2 50-70 %
Limfosit% 20.5 25-40 %
MID% 4.3 4.0-11.0 %
Gran# 4.80 2.50-7.50 Ribu/ul
Limfosit# 1.3 1.25-4.0 Ribu/ul
MID# 0.3 Ribu/ul
Laboratory 8-3-2017 (RSUD Ulin)
Examination Result Normal value
Random Blood Glucose 184 <200 Mg/dl
SGOT 43 0-46 U/I
SGPT 38 0-45 U/I
Urea 45 10-50 Mg/dL
Creatinine 1.5 0.7-1.4 Mg/dL
Working Diagnosis

Moderate Head Injury GCS 12

(E3V4M5) + ICH a/r parietal dextra +
Hypertension Grade I + DM Type II
controlled
Management
Head up 30 degree
O2 Nasal Canul 3 LPM
IVFD NS
Analgetic
H2 blockers
Antibiotic

Co. to neurosurgery:
Hospitalized
 6. Mr. Pramadita/ 29 y.o/3.30 am

Chief Complain:
Pain at left chest
History of Current Disease (autoanamnese):
Patient brought to the hospital with chest pain after
traffic accident since 2 hours before admission. The
mechanism of accident is patient that sit at the corner
of the street hitten by motorcycle with moderate speed
from left behind him. Then patient dragged 2 meter and
there is scretch at left side of body (head, shoulder,
hand, chest, knee and leg). Dizziness (-) headache (-)
seizure (-) history of unconsciousness (-) bleeding from
ear/nose/mouth (-/-/-)
Primary survey:
A : clear, without c-spine control
B : RR 19 x/m, symetrical chest move, Rh (-/-), Wh (-/-)
C : HR : 78 x/m, regular, strong, BP: 120/80mmHg
D : GCS 15: E4V5M6, pupil isokor, round 4mm/4mm, direct and indirect light
reflex +/+, Parese (-/-)

Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 7 hours before
E = Environment on the street
 Physical
Examination
Head : simetric, vulnus excoriatum a/r frontoparietal sinistra 3x0,5cm active
bleeding (-)
Head Eye : Anaemic conj. (-/-), icteric sclera (-/-)
Mouth : Moist mucous membrane,
Neck : Increasion level of JVP (-), enlargement lymph node (-)

I : symmetric respiratory movement, retraction (-), pain when full

inspiration (-) bruise (-)
Chest P : symmetric VF
P : Sonor at all lung felds
A : symmetric VBS, no rhonchi, no wheezing

I : distension (-) bruise (-)

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

Extremities warm extremities, CRT < 2

Clinical Picture

Local state a/r frontoparietal sinistra:

Look: Vulnus excoriatum 3x0,5cm, active bleeding (-)
Feel: Tenderness (+) Crepitation (-)
Clinical Picture

Local state a/r supra scapula sinistra:

Look: Vulnus excoriatum
Feel: Tenderness (+)
Clinical Picture

Local state a/r hemi thorax sinistra:

Look: Vulnus excoriatum
Feel: Tenderness (+)
Clinical Picture

Local state a/r dorsum manus sinistra:

Look: Vulnus excoriatum 2x1cm
Feel: Tenderness (+) crepitation (-)
Clinical Picture

Local state a/r genue sinistra:

Look: Vulnus excoriatum 2x2cm active bleeding (-)
Feel: Tenderness (+) crepitation (-)
Clinical Picture

Local state a/r dorsum pedis sinistra et malleolus lateral sin

Look: Multiple vulnus excoriatum, active bleeding (-)
Feel: Tenderness (+) crepitation (-)
Thorax Photo 8.03.2017
Fracture oblique incomplete costae VII posterior
Working Diagnosis

Mild Head Injury with GCS 15 +

Fracture oblique incomplete costae
VII posterior + Multiple vulnus
excoriatum
Management
Wound toilet
IVFD NS
Analgetic

Co to Thorax-Cardiovascular Surgery:
Observation Vital sign and sign of hemato/pneumothorax (chest
pain/dypsnea)
 7. Mr. Sunarko/ 26 y.o/03.39 am

Chief Complain:
Decrease of consciousness
History of Current Disease:
Patient brought to the hospital with chief complain
Decrease of consciousness since 8 hours before
admission. Patient has founded by his family with
unconsciousness condition and the mechanism of
trauma is unknown. After the accident patient brought
to Tanah Bumbus hospital but caused by patients
family want to refer to Ulin Hospital, patient has refered
to Ulin. History of nausea / vomiting (-/-), cephalgia (-)
and bleeding from nose (+), ear (-/-), mouth (+). GCS
from Tanah Bumbu hospital is 6 (E1V1M4)
Primary survey:
A : unclear, caused by blood accumulation, with c-spine control, gargling (+)
B : Spontaneous, simetrical movement,
C : HR : 122 x/m, regular, strong,
D : GCS 7: E1V2M4, pupil isokhor, round 3mm/3mm, light reflex +/+, Lateralization (-/-) ,
BH (-/-), BS (-/-), BR (-/-), BO (-/-)

Secondary survey:
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 5 hours before accident
E = Environment on the street
RR: 36 x/minutes, SpO2: 97% with 12 LPM
 Physical
Examination
Head : Facial Swelling (+), periorbital swelling, hematoma temporoparietal
sinistra, vulnus laceratum a/r supraorbita d/s sutured and laseratum infraorbita
sutured
Head Eye : Anemic conj. (-/-), icteric sclera (-/-), edem palpebra (-/-), brill haematoma
(+/+)
Mouth : Moist mucous membrane, blood (+)
Neck :Increasion level of JVP (-) lacerated (-)
I : Symmetric respiratory movement, no retraction, vulnus excoriatum
10x3cm
Chest P : Symmetric VF
P : Sonor at all lung felds
A : symmetric VBS, no rhonchi, no wheezing

I : distension (-) wound (-) hematoma(-) bruise (-)

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

warm extremities, CRT 2, vulnus excoriatum a/r digiti II-V manus

Extremities dextra and multiple vulnus excoriatum a/r genue dextra et sinistra.
Neurological state
GCS E1V2M4
Pupil reflex (+/+) isokhor
Patological reflex (-/-)
Physiological reflex (+2/+2)
Lateralization (-/-)
Maxilofacial state
Rima orbita
L: step of (+) vulnus laceratum sutured
F: Crepitation (+)
Maxilla
L: Swelling (+)
F: Crepitation (+), floating maxilla (-)
Mandibula
L: Swelling (+)
F: Unstable mandibula (-)
Zygoma
L: Swelling (+), step of (+)
F: Crepitation (+)
Clinical Picture

a/r hemithorax dextra

vulnus excoriatum 10x3cm
Local Status

At regio patella dextra et sinistra

Multiple vulnus excoriatum

Local Status

At regio digiti manus II-V dextra

Multiple vulnus excoriatum

CT SCAN

EDH Frontal dextra

3D Skull

Fracture of os Frontal, orbita rime, zygoma, and maxila dextra

Working Diagnosis
Severe head injury with GCS 7 (E1V2M4) + EDH a/r
Frontal dextra + Fracture of os Frontal, orbita rime,
zygoma, and maxila dextra + multiple vulnus
excoriatum
Management
CT-Scan Head trauma
Cervical and thoracal photo
IVFD NS
Antibiotic
Analgetic
H2 Blocker

Co. to Neuro Surgery:

CT Scan head if Primary survey clear
Intubation

After there is a CT-Scan:

Pro CITO Craniotomy Evacuation

Co. to Plastic Surgery:

Conservative, Hospitalized and pro ORIF Elective
THANK YOU