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1. Mrs. Siti Zahrah/50 y.o/1.19.51.

55

Chief Complain:
weakness
History of Current Disease:
patient came with weakness since 4 month before
admission, she was look weak after underwent
chemotheraphy for cervix cancer 4 month. She has
history of seizure 1 weak ago, five times, 3 minue,
general type seizure, she was unconciousness after
seizure. she complained a mass on left side of anus,
the mass was growing slowly since 3 days ago, pus
(+). She was referred from RS ratu zalecha with
diagnose fistula perianal. Meal (<) drink (+),
defecation (+) urination (+), nausea (-) vomiting (-).
Vital sign
BP : 80 / 40 mmhg
HR : 96 Bpm
RR : 18 tpm
T : 37,5 0C
GCS 13 E3V4M6
Physic
Diagnostic
Head : simetric, normocephal
Eye : Anemic conj. (+/+), icteric sclera (-/-),
Head Mouth : Moist mucous membrane,
Neck :Increasion level of JVP (-)
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
Chest P : Sonor at all lung fields
A : symmetric VBS, rhonchi , no wheezing
I : distention (-)
A : Bowel sound normal
Abdomen P : tenderness (-)
P : tympani (+)

warm extremities (+), edema (-),


Extremities parese (-),

Sphincter anii constrict well, smooth


DRE mucosa, ampula colapse (-), mass (-)
Fecal (+) blood (-)
St. Localize at left perianal
Fistula (+) 6x4 cmm,
reddish skin color, pus (+)
Working Diagnosis

Left Perianal fistel post laparotomi operation dt


ovarian solid mass+ post chemotheraphy
Management
Oxygenation
IVFD Futrolut : D10% 10 dpm
Inj OMZ 1x1 amp
Inj ketorolac 1x1amp
Inj diaz amp (kp)

Co.to. Digestive surgey:


Join with obgyn
Pro fistuloraffi and colostomy
hospitalized
2. Mr. M. Alwi/ 19 y.o

Chief Complain :
Inserted cable into penis accidentally
History of Current Disease:
patient inserted cable into his penis accidentally 4
hours before admission. He has difficulty to urinate
since 1 year ago. Then he accustomed inserting a
cable into his penis and pulling it out to widening his
penis orifice for help him urinate. He has doing it more
than 10 times. Last night when he wanted to insert a
cable in bathroom, he slipped and the cable was
inserted all, and cant be pull out. Urination (+) mixed
with blood clot. He felt pain especially when urinate.
Primary survey :
A : Clear
B : RR 18 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP:110/70 mmhg HR: 73x/m;
D : GCS 15 E4V5M6, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal 4 hours before accident
E = Environment on the bathroom
Physic
Diagnostic
Head : simetric, normocephal
Eye : Anemic conj. (+/+), icteric sclera (-/-),
Head Mouth : Moist mucous membrane,
Neck :Increasion level of JVP (-)
I : Symmetric respiratory movement, no retraction
P : Symmetric VF
Chest P : Sonor at all lung fields
A : symmetric VBS, rhonchi , no wheezing
I : distention (-)
A : Bowel sound normal
Abdomen P : tenderness (-)
P : tympani (+)

warm extremities (+), edema (-),


Extremities parese (-),

Sphincter anii constrict well, smooth mucosa,


ampula colapse (-), mass (-) prostate: palpable,
DRE soft, regular edge, tenderness (-); Fecal (+) blood
(-)
Clinical Picture
St. Localize
Flank area
D: tenderness (-) mass (-)
S: tenderness (-) mass (-)
CVA
D: tenderness (-)
S: tenderness (-)
Working Diagnosis

Corpus allenum dt cable


Management
VS obs
Inj ceftriaxone 2x1g
Inj tramadol 2x1
Inj tranexamid acid 3x1
Inj ranitidin 2x1

Co.to. urology:
Pro USG urology
Pro urethrography
hospitalized
3. Mr. Abdiansyah/63 y.o./1.23.01.41

Chief Complain :
Pain on left cheek
History of Current Disease:
patient came with pain on his left cheek since 1
day before addmission. He fell from ladder 3 meter
in height. He fell with face blow the ground. He
work as construction worker. History of
unconciousness (-). Bleeding on ear/ nose/ mouth
(-/+/-). Nausea (-) vomite (-). He also felt pain on
his left forearm. He barely open his mouth after the
accident.
Primary survey :
A : Clear
B : RR 18 x/m, symmetrical shape and movement
symmetrical breathing sound
C : BP:140/90 mmhg HR: 83x/m;
D : GCS 15 E4V5M6, pupil round equal 3 mm, light reflex +/+
lateralization (-) , BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication
P = Past illness (-)
L = Last meal 4 hours before accident
E = Environment on the his work place
Physic
Diagnostic
Head : simetric, normocephal, hematom (+)
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head Mouth : Moist mucous membrane,
Neck :Increasion level of JVP (-)

I : Symmetric respiratory movement, no retraction


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

I : distention (-)
A : Bowel sound normal
Abdomen P : tenderness (-)
P : tympani (+)

warm extremities (+), edema (-),


Extremities parese (-)
Clinical picture
Clinical Picture
St. Localize at zygoma
dextra
L: swelling (+) deformity
(+)
F: tenderness (+)
Clinical Picture
St. Localize at left forearm
L: swelling (+) deformity
(+)
F: tenderness (+)
M: ROM limited dt pain
Skull X ray
Working Diagnosis

Left zygoma fracture+ close fracture distal end


radius frykmann type 1
Management
VS obs
IVFD RL
Antibiotic
Analgetic
H2 Blocker

Co.to. Plastic surgery:


Hospitalized

Co. To orthopaedic
Anterior slab
Pro elective ORIF