17-04-2013

MORNING SHIFT
10.00-16.20

Identity Diagnose Therapy
Mr. LH, 34 years old, as Vulnus laseratum on IVFD RL 20 tpm
... penis Ketorolac Inj. 1x1
amp/IV
debridement
IO, male, 23 y.o, Patient came from IVFD RL 20 tpm
Kupang city hospital, Cefotaxime Inj. 2x1
with diagnosed gr/IV
appendicitis and Ketorolac Inj. 3x1
urinary tract infection amp/IV
Ranitidin 2x1 amp/IV
 
identity diagnose therapy

Miss MD, 29 Colic abdomen e.c Ketorolac inj 30mg

thn, Manutapen suspect urolithiasis extra
Renax 3x1 tab
Ranitidin 2x1 amp
Ciprofloxacin 2x1 tab
Mefenamic acid 3x1
tab
 NIGHT SHIFT
16.20-22.20

Identity Diagnose Therapy
Mr. A, male, 70 y.o •Vulnus laceratum et Wound toilet
tibialis anterior dextra Hecting treatment
•Urgency Hipertension ATS inj. 1 amp/IM
Amoxicillin 3x500mg
Mefenamic acid
3x25mg
Mr. FB, male, 53 y.o, a Vulnus laceratum et Wound toilet
student auriculae dextra Hecting treatment
ATS inj. 1 amp/IM
Amoxicillin 3x500mg
Mefenamic acid
3x500mg
 Identity Diagnose Therapy
Mr. M, male, 26 y.o Mild head injury Wound toilet
Hecting treatment

 IVFD RL 20tpm
Ranitidin 50 mg/IV
Ketorolac 30mg/IV
Piracetam 3 gr/IV
ATS inj. 1 amp/IM

Mr. AJT, male, 25 y.o Colic abdomen e.c Ranitidin 25 mg 1 amp

urinary tract stone Ketorolac 30 mg 1 amp
Ciprofloxacin 500mg
2x1 tab
Spasminal 3x1
 
Identity Diagnose Therapy
Mrs. YP, female, 19 y.o Colic abdomen e.c IVFD RL 20 dpm
suspect acute Ceftriaxone 2x1 gr IV
appendicitis Ketorolac 3x1 Ampule IV
Plan for abdominal USG

Mr. RP, male, 19 y.o Multiple excoriatum •Hospitalized

•O2 3 lpm
•IVFD RL 20 dpm
•Ranitidine 2x50mg/IV
•Ketorolac 3x30 mg/IV
•Piracetam 4x3 gr/IV
•Dexamethasone 3x1 amp
•DC
 
Identity Diagnose Therapy
Mrs. RL, female, 47 y.o Dizziness + myalgia Ketorolac 30 mg IV
post trauma 4 hours observation

Mr. A, male, 22 y.o Moderate head injury Wound toilet

Hecting treatment
ATS inj. 1 amp/IM
Amoxicillin 3x500mg
Mefenamic acid 3x500mg
 BIODATA

 Name : Mr. LH
 Age : 34 years old
 Sex : Male
 Address : Oesapa
 Job :
 Anamnesis
 Chief Complaint :

pain and wound on penis and left hip after iron drop top of the car
 MOI
patient came to ER after he got an injured n his said on left hip and his
penis. Patient said, he got injured when he try o repair the car, and
suddenly iron from the upper floor drop and hit the right leg and his
penis. After the accident patient really feel painful on the penis and got
bleeding on his penis. After the accident friend of the patient take his
to the ER.
 Primary Survey

 A: clear
 B : RR: 20 times in a minute
 C : Blood preasure : 130/80 mmHg , Pulse: 84
times/minute, reguler.
 D : GCS E4V5M6
 E : a wound on his penis (glands penis with active
bleeding)
 Secondary Survey
 GCS : E4 V5 M6

 Eye : anemic (-/-), pupil isokor (+/+), icteric (-/-)
 Ear : In normal limit
 Nose : In normal limit
 Throat : Normal
 Thorax

 Inspection : chest expansion bilateral simetric,
pattern of respiration is abdominothoracal
 Palpation : vocal fremitus R=D
 Percusion: sonor (+/+)
 Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)
 Abdomen

 Inspection : distended (-)
 Auscultation : peristaltics (+) still normally
 Palpation : tenderness pain (-), mass (-)
 Percusion : timpany sound (+)
 Extremity

 Look : normal
 Feel : pain on the right upper leg (+), bruised (-)
 Move
 ROM : normal

 Laboratorium

CBC :
 WBC : 14.800/ul
 Hb : 15,9 gr/dl
 Platelet : 411.000/ul
 Assessment

 Vulnus laseratum at glands penis
 Planning therapy

 IVFD RL 20 tpm
 Ketorolac Inj. 1x1 amp/IV
 Wound care + hecting
 Observation (force return)

Second cases

 BIODATA

 Name: IO
 Age : 23 years old
 Sex : Male
 Address : Bakunase
 Job : unknown
 Anamnesis
 Chief Complaint :

painful on lower abdomen since four day before enter the Hospital
 NOI
patient came from Kupang City Hospital with diagnosed Appendicitis
and urinary tract stone. The patient have history of abdominal pain
since 4 days before enter the hospital. The charecteristic of pain is on
the lower abdomen, suddenly, intermittent, and there is no pain
alteration with positional movement. Migration pain and history of
fever is negative. But he feel pain when coughing. Patient have
nausea, and vomit today . His urine color was change to red but he
didn’t feel any pain when he urinate , the feses little bit soft. He got
papaverine, omeprazole and nephrolit from the Kupang City Hospital.
 Primary Survey

 A: Clear
 B : RR: 30 times in a minute
 C : Blood preasure : 100/80 mmHg , Pulse: 100
times/minute, reguler.
temperature : 36,6o
 D : GCS E4V5M6
E:-
 Secondary Survey

 Eye : anemis (-/-), pupils isokor (+/+), icteric (-
/-)
 Ear : In normal limit
 Nose : In normal limit
 Throat : Normal
 Thorax

 Inpection : chest development simetrics, reguler,
thoracoabdominal, bruise (-)
 Palpation : vocal fremitus R=D, crepitation (+)
 Percusion: sonor (+/+)
 Auscultation : vesicular (+/+), ronchi (-/-), wheezing
(-/-)
 Abdomen

Inspection : distended (-), dunphy's sign (+)
Auscultation : intestinal sounds normal
Palpation : tenderness pain (-), pain on
palpation (+) at right illiaka region
(Mcburney area (+)), and suprapubik
region, mass (-), rebound pain (-), psoas
sign (-),
Percussion : timpany sound (+)
 Extremity

 Look : normal
 Feel : normal
 Move
 ROM : normal
 Laboratorium
CBC :
 WBC : 35.500/ul
 Lym : 0,76 x 103 / ul 
 Mid : 1,27 x 103 / ul
 Gra : 33,5 x 103 / ul
 Lym %: 2,1%
 Mid %: 3,6%
 Gra %: 94,3%

UL : protein +3
 Eritrosit sel +4, sedimen : 10-20/LP
 Leukosit sel (-)
 ALVARADO SCORE

 Migration of pain to lower right quadrant :
0
 Anorexia :1
 Nausea and vomitting :1
 Tenderness in right lower quadrant :0
 Rebound pain :0
 Elevated temperature :0
 Leucocytosis :1
 Shift WBC count to the left :1
Total = 4 (Appendicitis unlikely)

 Assessment

 Colic abdomen e.c suspect acute appendicitis
Ddx/ urinary tract stone
 Planning therapy

 IVFD RL 20 tpm
 Cefotaxime Inj. 2x1 gr/IV
 Ketoroloc Inj. 3x1 amp/IV
 Ranitidine 2x1 amp
 Hospitalization
 Pro USG at ward
Third Casses

 BIODATA

 Name : Miss MD
 Age : 29 years old
 Sex : Female
 Address : Manutapen
 Job : Unknown
 Anamnesis
 Chief Complaint :

pain on the lower abdomen since one day before went to the Hospital
 NOI
The patient came to ER because she felt pain on lower abdomen, since
one day before went to the hospital. Charesteristic pain is intermitten,
with fever and vomit. Patient also feel pain when want to urinate, and
the color of urin is brown. Patient has been diagnosed with urolithiasis
about month’s ago and have planned to operate but cancelled. The
patient got medicamentosa but there is no improvement.
 Physical examination

 The result of physical examination shown painful on
CVA with knocking, suprapubic region with
palpation
 Lab result

 Patient has been planned for check urine, complete
blood count, urine, creatinin, but cancelled.
 assesment

 colic abdomen ec suspect urinary tract stone
 Therapy

 Ketorolac inj 30mg extra
 Ranitidin inj 1 ampul/IV
 Renax three times a day capsule
 Ciproploxacin twice a day
 Asam mefenamat there times a day
 outpatient
 BIODATA

 Name : Mr. A
 Age : 22 years old
 Sex : Male
 Address : Fatululi Oebobo
 Anamnesis
 Chief Complaint :

loss of conciousness caused by motorcycle accident
 MOI
The patient referred from Kupang City Hospital, diagnosed with
moderate head injury and a history of motorcycle accident without any
further information about the crash. The patient suffered with loss of
conciousness and blood from nose present. Nausea and vomit (-),
blood from ear (-).
 Primary Survey

 A: rinorrhea (+)
 B : RR: 23 times in a minute
 C : Blood pressure : 130/80 mmHg , Pulse: 90
times/minute, reguler.
 D : GCS E1V2M4
 E : bruise at right and left shoulder, vulnus
excoriatum at gluteal sinitra and maleolus medial
sinistra, vulnus laceratum at tibialis lateralis dextra
 Secondary Survey

 GCS : E4 V5 M6
 Eye: anemic (-/-), light reflex (+/+), isokor, icteric (-
/-)
 Ear : In normal limit
 Nose : rinorrhae (+)/(+)
 Throat : Normal
 Thorax

 Inspection : abrasion on the lateral side of 6th rib of
left chest. Development simetrics, reguler,
abdominothoracal
 Palpation : vocal fremitus R=D
 Percusion: sonor (+/+)
 Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)
 Abdomen

 Inspection : distended (-), bruise (-)
 Auscultation : peristaltics + normal
 Palpation : tenderness pain (-), mass (-)
 Percusion : timpany sound (+)
 Extremity

 Look
abrasion on left foot and right leg
 Feel
normal
 Move
 ROM : can not be evaluated







 Test Name

Value
WBC 33,6.103
Lymp 3,04.103
Granulocyte 28,4.103
Hb 13,9
HCT 39,6%
RBC 4,51.106
PLT 240. 103
UL: leu (-)
Nitrit (-)
glukosa +1
prot +3
 Assessment

Moderate head injury
Vulnus Excoriatum Multiple
 Planning Diagnose

 CBC
 CT scan
 Planning therapy

• Hospitalized
• O2 3 lpm
• IVFD RL 20 dpm
• Ranitidine 2x50mg/IV
• Ketorolac 3x30 mg/IV
• Piracetam 4x3 gr/IV
• Dexamethasone 3x1 amp
• DC
 BIODATA

 Name : Miss. YPRN
 Age : 19 years old
 Sex : Female
 Address : Tanah Merah
 Date of ER admission : 29th April 2013 at 16.19 PM
 Date of Room Admission: 29th April 2013 at 22.00 PM
Cempaka Bed.A5
 Anamnesis
 Chief Complaint :

Right Lower Abdominal Pain
 MOI
The patient complained about right lower abdominal pain since 3 days

ago accompanied by an epigastric pain. The pain was felt all day and

worsened by cough, relieved by lied down. There was a history of

fever, 5 days before admission. Relieved by fever relieved drug. There

was a history of Vomit twice. Anorexia (+), defecation and urination

was normal.
 Primary Survey

 A: clear
 B : RR: 20 times in a minute
 C : Blood pressure : 110/70 mmHg , Pulse:
72times/minute, reguler. Temp: 37,3 oC
 D : GCS E4V5M6
 E :-
 Secondary Survey

 GCS : E4 V5 M6
 Eye: anemic (-/-), light reflex (+/+), icteric (-/-)
 Ear : In normal limit
 Nose : In normal limit
 Throat : Normal
 Thorax

 Inspection : chest development simetrics, reguler,
abdominothoracal
 Palpation : vocal fremitus R=D
 Percusion: sonor (+/+)
 Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)
 Abdomen

 Inspection : distended (-),
 Auscultation : peristaltics + normal
 Palpation : tenderness pain (+), Rebound tenderness
(+), McBurney Point pain (+), Migrate Pain (+), mass
(-)
 Percusion : timpany sound (+)
 Extremity

 Look
normal
 Feel
normal
 Move
 ROM : normal

 Labs
Test Name
 Value
WBC 11,9.103
Lymp 2,97.103
Granulocyte 8,40.103
Hb 13,6
HCT 43,2%
RBC 5,42.10
PLT 237

Malaria -
UL
Leukocute,Prot, Ery, -
Glu, PST
 Assessment

 Colic Abdomen ec Susp Acute Appendicitis
 Planning therapy

 IVFD RL 20 dpm
 Ceftriaxone 2x1 gr IV
 Ketorolac 3x1 Ampule IV
 Plan for abdominal USG
 

THANK YOU