Emergency Report

May 24th - 25th, 2014

Resident on duty:
Dr. Andika August Winata
Chief on duty:
Zainul Muttaqien

Co-Ass on duty:
Redha, Fath, Ferisa, Shinta, Fatimah,
Sari

PATIENT LIST
Oncology surgery

Patients List
No

Identity

1. Siti
Mahdalena/
54 yo/
111.02.77

Admission to
E.R.

24th June
2014/
14.30

Diagnosis

Anterior
Dislocation of
the right
Shoulder Joint

Management

Observation Vital Sign

Analgetic
H2 Blocker
Consult to Orthopaedic
Surgeon
Closed Reduction

2. Arbain/ 33 24th june

yo/ 11.02.95 2014/
19.35

Peritonitis
diffuse ec
abcess hepar
rupture

IVFD NS
Antibiotic
Analgetic
H2 Blocker
Complete Lab Check
Thorax and BNO rontgen
DC
NGT
Fluid Balance

Patients List
No

Identity

Admission to
E.R.

3. Herman/ 74 24th June

yo/ 11.02.96 2014/
20.35

Diagnosis

Management

Tetanus Phillips
score 12
(moderate)
Ablett grade IIIIV

IVFD RL : D5
NGT
Tetanus Immunoglobulin 3000
IU multi site
Antibiotic
H2 Blocker
Diazepam drip
Hospitalized
Autonomic Storm 23.00
Consult Internist
Hospitalized ICU
Diltiazem
Midazolam drip

Patients List
No

Identity

4. Bidin/ 47
yo/
111.02.94

Admission to
E.R.

24th June
2014/
18.55

Diagnosis

Management

1. Siti Mahdalena/ 54 yo/ 24th June 2014/ 14.30

Chief complain: Pain at right shoulder
History : 2 hours before admission, when patient rode
motorcycle in a slippery road, suddenly she fell on her
own. She fell with her right hand hit the ground first.
After the accident, she felt pain in her left shoulder, and
she went to masseur, but her complaint didnt gone.

List of patient

Primary Survey

List of patient

4 Hour before
admission
On the road

List of patient

Physical Examination
Head/Neck

List of patient

Clinical picture

List of patient

Clinical Picture

Laboratory Findings

Hb
: 12,9
WBC
: 13,7
RBC
: 4,54
Hematocrite : 38,1
Plt
: 260
PT/APTT : 9,3/19,3
BSN
: 173
SGOT/SGPT : 68/56
Ur/Cr
: 17/0,74

Na
K
Cl

: 141,8
: 5,09
: 105,6

List of patient

Thorax AP 24th June 2014

Shoulder X-Ray 24 June 2014

Shoulder X-Ray Post Reduction

Working Diagnosis
Anterior Dislocation of the right Shoulder Joint

List of patient

Management
Observation Vital Sign
Analgetic
H2 Blocker
Consult to Orthopaedic Surgeon
Closed Reduction

2. Arbain/ 33 yo/ 24th June 2014/ 19.35

Chief complain: pain in stomach
History : 5 days before admission, patient complaint that his
stomach getting bigger and he felt pain in his abdomen.
Pain start on his upper right abdomen, intermitten, and not
spreading to the back. 2 weeks before admission, he had
bloody and mucous diarrhea, and felt pain when he
defecate, he also had intermitten fever. He also vomiting, 2
times, yellow colored, and his body become yellow
(jaundice). No history of trauma, no history of jaundice.
Occupation : merchant
History of smoke cigarette : 2 packs a day
Alcoholism (+)
List of patient

Vital Sign

GCS : E4V5M6
HR
: 104 x/minutes
BP
: 110/80 mmHg
RR
: 24 x/minutes
T
: 36,9C

Physical Examination
Head/Neck

List of patient

Clinical picture

List of patient

Clinical Picture

Insp :Distended, mass (-)

Ausc: Bowel sound (-)
Palp :Pain (+), defans
muscular (+)
Perk :Hypertympani

Rectal Toucher

Mass (-)
Strong TSA, ampulla not collapse
Slippery mucose
Prostat palpable, 2 bread finger, nodule (-)
Handscoen : mucous (-), blood (-), feces (-)

Laboratory Findings 24th June 2014

Hb
: 12,8
WBC
: 29,8
RBC
: 40,4
Hematocrite : 38,1
Plt
: 709
PT/APTT
: 15,3/25,2
BSN
: 103
SGOT/SGPT : 43/40
Ur/Cr : 34/0,76

Bilirubin
Total : 1,85
Direct : 1,80
Indirect : 0,05
Na
: 135,0
K
: 4,67
Cl
: 99,7

List of patient

Thorax X-Ray 24 June 2014

BNO 3 Position 24th June 2014

BNO 3 Position 24th June 2014

Working Diagnosis
Peritonitis diffuse ec abcess hepar rupture

List of patient

Management

IVFD NS
Antibiotic
Analgetic
H2 Blocker
Complete Lab Check
Thorax and BNO rontgen
DC
NGT
Fluid Balance

3. Herman/ 74 yo/ 24th June 2014/ 20.35

Chief complain: stiffness in mouth
History : 2 weeks before admission, patient had wound in
his foot, after he fell down and his foot hit the stone, his
foot got lacerated wound. He didnt wash his wound, and
this morning he felt stiffness in his mouth when he try to
open it. There is no stiffness in stomatch, sweating, and
hard to breath. No abnormality in defecate and urinate.

List of patient

Vital Sign

GCS : E4V5M6
HR
RR
BP
T

: 88 x/minutes
: 22 x/minutes
: 170/100 mmHg
: 36,7C

Physical Examination
Head/Neck

List of patient

Clinical picture

List of patient

Clinical Picture

Insp :Distended, mass (-)

Ausc: Bowel sound (-)
Palp :Pain (+), defans
muscular (+)
Perk :Hypertympani

Autonomic Storm, 23.00

HR : 190
RR : 22
TD : 200/100

Laboratory Findings 24th June 2014

Hb
: 14,6
WBC
: 6,9
RBC
: 5,42
Hematocrite : 44,8
Plt
: 291
PT/APTT
: 11,4/21,3

List of patient

Working Diagnosis
Tetanus Phillips score 12 (moderate)
Ablett grade III - IV

List of patient

Management
IVFD RL : D5
NGT
Tetanus Immunoglobulin 3000 IU multi site
Antibiotic
H2 Blocker
Diazepam drip
Hospitalized
Autonomic Storm 23.00
Consult Internist
Hospitalized ICU
Diltiazem
Midazolam drip

4. Bidin 47 yo/ 24th june 2014/ 18.55

Chief complain:
History :

List of patient

Vital Sign

GCS : E3V5M6
HR
RR
BP
T

: 94 x/minutes
: 28 x/minutes
: 180/100 mmHg
: 36,9C

Physical Examination
Head/Neck

List of patient

Clinical picture

List of patient

Laboratory Findings 24th June 2014

Hb
: 16.0
WBC
: 11,4
RBC
: 5,40
Hematocrite : 48,7
Plt
: 230
PT/APTT
:
BSN
: 136
SGOT/SGPT : 26/26
Ur/Cr : 38/1,01

Na
K
Cl

: 141,5
: 3,52
: 101,4

List of patient

Thorax AP 24th June 2014

CT Scan 24th June 2014

CT Scan 24th June 2014

Working Diagnosis

List of patient

Management