Emergency Report

December 22nd-23rd, 2014

Resident on duty:
dr. Alma Wijaya

Chief on duty:
Adit
Team:
Pras, Erika, Strata, Lucky, Nida, Vista

PATIENT LIST
Minor surgery

:2

Oncology surgery

Digestive surgery

Thorax cardiovascular surgery

Plastic surgery

Urology surgery

:3

Neurosurgery

:1

Pediatric surgery

Orthopedic

:1

Total

:7

Patients List
No

Identity

Admission to
E.R.

Diagnosis

Management

Mr. Fajar, 26
yo/

December
22nd, 2014
at 15.15

Severe Head Injury

GCS E2 Vx M5+
Cerebral contusion
+
SAH+
Susp.
Fracture
Basis
Cranii
Fossa
Anterior Et Media +
left
Pulmonary
contusion+ Closed
Fracture of right
Femur Midle 3rd
Cominutive
Displaced+ Closed
Fracture
right
Distal End Radius
fryckman type III

Consult to neurology surgery:

-Obsv. Vital sign
-Head up 30 degree
-IVFD NS 2500cc/24 hours
-Antibiotic
-H2 Blocker
-Analgetic
-Hospitalized ICU
Consult to Cardio Thoracic Vascular
surgery:
-X-ray Thorax serial/ 12 hours
-Conservative therapy
Consult to ortophaedic:
-Skin traction right femur
-Spalk immobilisation for
antebrachii fracture
-Pro ORIF elective

Patients List
No

2.

3.

Identity

Admission to
E.R.

Diagnosis

Mr. Rizkian
12 yo/

Lacerated wound
December
22nd 2014 at at right antebrachii
region
18.05

Mr. Arkasi 61
yo/

Obsv. Scrotal mass

e.c susp inguinal
December
22nd 2014 at bladder hernia (
post Hernioraphy)
18.40

Management

Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker
Consult to digestive surgery:
Obsv. Vital sign
Co. Urology
Consult to urology:
Antibiotic
H2 Blocker
Analgetic
Pro uretrocystography
If cant urinate, DC cateter small
caliber (RF)
Join treatment with digestive

Patients List
No

Identity

Admission to
E.R.

Diagnosis

Vesico
4. Mr. Rusbani December Fistula
post
50 yo/
22nd 2014 Cutaneus
open
at 21.00
prostatectomy +
Anemia
+
Trombositopeni +
hypoalbunemia+
severe Sepsis

Management

Co Urology surgery:
Observation of Vital Sign
O2 6 lpm
IVFD Rl : D5 3:1 2000cc/day
Antibiotic
Analgetic
H2 Blocker
Blood Transfution 2 kolf
Albumin injection

Patients List
No

Identity

5. Mr. Samsul
Bahri 45
yo/

Admission to
E.R.

Diagnosis

December Mild head injury

22nd 2014 GCS 15 +
lacerated wound
at 22.30
at right
periorbita region
+ lacerated
wound at right
knee region

6. Mr.
December
Open
Mulyana 55 22nd 2014 Post
Cystotomy
d.t
yo/
at 22.55
Susp
Stricture
Uretra Posterior

Management

IVFD RL
Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker

IV Line
Antibiotic
analgetic
H2 blocker
Co Urologist surgery:
Pro BVUC

Patients List
No

Identity

7. Mr. Samuel
Salodong
31 yo/

Admission to
E.R.

Diagnosis

December Closed fracture

23rd 2014 of the right tibia
distal third (intra
at 02.15
artikular)
comminutive
displaced

Management

Consult to Ortopaedy
Posterior slab
Analgetic
H2 Blocker
Pro ORIF elective

1. Mr. Fajar, 26 yo/ December 22nd, 2014 at

15.15
Chief complain: Decreased of consciousness
History : 15 hours before admissions, when pts was riding
his motorcycle while drunk. Pts lose his balanced and fell
to the ground. His head and chest were bumped to the
road. History of fainting +, vomiting (-), bleeding from
ear/mouth/nose (+/+/+), pts helped by pedestrians, and
brought to Tamiang Layang Hospital. There they foud
deformity on his right hand and leg, so he were treated
with spalc. Then pts referred to Ulin Hospital for further
treatment.

Primary Survey

Clear (-) with ETT , snoring (-), gurgling(+), stridor (-)

Clear, RR : 30 tpm, simetric respiratory movement, VBS simetry,

Pulse 136 tpm, reguler, lift strong, the extremities warm

BP: 100/70 mmHg

GCS E2VxM5, P 3mm/3mm, light reflex +/+, parese -/-

Rh -/+ deep and quick

Secondary Survey
Head/Neck

Eyes : racoon eyes (+/+), anemic conjungtivae (+/+), icteric sclerae (-/-)
Nose : rhinohargia (+)
Ear : otohargia (+), battle sign (+)
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-), cephal
hematom (-)

Chest

I : symmetric respiratory movement, lesion (+) a/r hemithorax sinistra

P : symmetric VF (+/+)
P : sonor at all lung
A : symmetric VBS+/+, rhonchi (-/+), wheezing (-/-)

Abdomen

Extremities

I : distention (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,
rebound tenderness (-)
P : Tympani

Warm, see status localized

(-)

IVFD rl,Analgetic, antibiotic, piracetam, anti

coagulant

(-)

20 hours before admission

On the road

Localized Status

Localized Status

a/r femur dextra:

L: edem (+), deformity (+), angulation
(+)
F: F movement (+)
M: limited

Localized Status

a/r cruris sinistra:

L: wound (+), edem (+), deformity (-)
F: Crepitation (-)
M: ROM active

Localized Status

a/r cruris dextra:

L: wound (+), edem (+), deformity (-)
F: crepitation (-)
M: ROM limited

Localized Status
a/r antebrachii dextra:
L: edem (+), deformity
(+), angulation (+)
F: crepitation (+)
M: ROM limited

Localized Status
a/r Capitis:
L: racoon eyes (+),
otohargia (+), Rhinohargia
(+)
Hematom (-), batlle sign (-)
F: crepitation (-)

Cervical X-Ray December, 22nd 2014

Thorax X-Ray December, 22nd 2014

Femur X-ray
December, 22nd 2014

Antebrachii X-ray
December, 22nd
2014

Pelvic X-ray December, 22nd 2014

Ct Scan December, 22nd 2014

LABORATORY FINDING

13,5Result

HEMATOLOGY
Parameter

Normal Value

December 22nd, 2014

Hemoglobin

10,6

14,0-18,0 g/dl

Lekosit

16,1

4,0-10,5 ribu/ul

Eritrosit

4,31

4,5-6,0 juta/ul

Hematokrit

31,4

42-52 vol %

Trombosit

151

150-450 ribu/ul

MCV

72,9

80-97 fl

MCH

24,5

27-32 pg

MCHC

33,7

32-38 %

Ureum

47

10-50 g/dL

Creatinin

1,3

0,7-1,4 mg/dL

GDP
SGOT/ SGPT

135
133/49

<200 mg/dL
0-45 U/I

23

PEMERIKSAAN

HASIL

RUJUKAN

PT

12,3
1,08
11,4
20,8
26,1

9,9-13,5 dtk

INR
Control Normal PT
APTT
Control Normal APTT

22,2-37 dtk

SATUAN

U/I

24

Working Diagnosis
Severe Head Injury GCS E2 Vx M5+ Cerebral
contusion + SAH+ Susp. Fracture Basis Cranii
Fossa Anterior Et Media + left Pulmonary
contusion+ Closed Fracture of right Femur
Midle 3rd Cominutive Displaced+ Closed
Fracture right Distal End Radius fryckman
type III

Management
Consult to neurology surgery:
- Obsv. Vital sign
- Head up 30 degree
- IVFD NS 2500cc/24 hours
- Antibiotic
- H2 Blocker
- Analgetic
- Hospitalized ICU
Consult to Cardio Thoracic Vascular surgery:
- X-ray Thorax serial/ 12 hours
- Conservative therapy
Consult to ortophaedic:
- Skin traction dextra
- Spalc for antebrachii
- Pro ORIF elective

2. Mr. RizkianSuri/
1250
yo/
December 22nd 2014 at
Yo/1-11-55-77
18.05
Chief Complain : Wounded hand
History :
an hours before admission, pts fell at his home while
carring a plate. The plate became broken and its
wounded his right arm. A lot of bleeding comes from
the wound. He wrap his wound with some of clothes.
Pts then brought to Ulin general hospital by his
family for further treatment.

Primary Survey

Clear (-), snoring (-), gurgling(+), stridor (-)

Clear, RR : 22 tpm, simetric respiratory movement, VBS simetry,

Pulse 72 tpm, reguler, lift strong, the extremities warm

BP: 110/70 mmHg

GCS E4V5M6, P 3mm/3mm, light reflex +/+, parese -/-

Rh -/-, wh -/-

Secondary Survey
Head/Neck

Chest

Abdomen

Extremities

Eyes : anemic conjungtivae (-/-), icteric sclerae (-/-)

Nose : epitaksis (-)
Ear : otohargia (-), battle sign (-)
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-), cephal
hematom (-)
I : symmetric respiratory movement
P : symmetric VF (+/+)
P : sonor at all lung
A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)
I : distention (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,
rebound tenderness (-)
P : Tympani

Warm, parese (-/-), see status localized

(-)

(-)

(-)

An hour before admission

At home

Clinical Pictures

Localized Status
a/r antebrachii:
L: edem (-), deformity (-), wound (+),
size diameter 5 cm, base wound fascia
(+)
F: tenderness (-), crepitation (-), pain
(+)
M: ROM Active

Post hecting

Working Diagnosis
Lacerated wound at right antebrachii region

Management
Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker

3. Mr. ArkasiSuri/
61 50
yo/
December 22nd 2014 at
Yo/1-11-55-77
18.40
Chief Complain : bump at scrotum
History :
since one year before admission, pts complaint that
there was a bump on his left scrotum. At the
begining, the bump could go back in and out. 10
days before admission the bump on his scrotum got
bigger and couldnt go in anymore. Defecate (+),
pain (+), urinate (+). Pts then seek treatment to
Amuntai hospital, he was operated but at durante
operation, hernia sach wasnt found. The operation
back then was imidiately stop. Pts then brought to Ulin
Hospital for further examination.

Physical Examination

Compos Mentis
BP: 130/100mmhg
P: 82 tpm
RR: 20 tpm
T: 36,6 C

CVA

I : wound (-/-), hematome (-/-)

P : mass (-/-), tenderness (-/-)
Flank Area
I : mass (-/-), hematome (-/-), wound (-/-)
P: mass , tenderness (-/-)
Suprapubic
I: improminent urinary bladder, wound (-), hematome (-), mass
(+)
P : tenderness (+)
Genitalia
OUE : bloody discharge (-), edema (-), stone (-)
38

Clinical Picture

 a/r scrotum and inguinal:

L: mass (+), size diameter 10 cm,

Mass at scrotal region

10cm in diameter
Solid consistencies
Reguler edge

 Surgical wound +

 Fibrosis at OUE

LABORATORY FINDING

13,5Result

HEMATOLOGY
Parameter

Normal Value

December 22nd, 2014

Hemoglobin

11,9

14,0-18,0 g/dl

Lekosit

11,7

4,0-10,5 ribu/ul

Eritrosit

4,26

4,5-6,0 juta/ul

Hematokrit

36,2

42-52 vol %

Trombosit

325

150-450 ribu/ul

MCV

85,1

80-97 fl

MCH

27,9

27-32 pg

MCHC

32,8

32-38 %

Ureum

30

10-50 g/dL

Creatinin

0,8

0,7-1,4 mg/dL

GDS
SGOT/ SGPT

272
43/48

<200 mg/dL
0-45 U/I

44

PEMERIKSAAN

HASIL

RUJUKAN

PT

12,8
1,11
11,4
27,6
26,1

9,9-13,5 dtk

INR
Control Normal PT
APTT
Control Normal APTT

22,2-37 dtk

SATUAN

U/I

45

X-ray Pelvic

X-ray Abdomen

USG

USG

Expertise

Right scrotum:
Seen bowel filling the right scrotum
Right testis looks unclear
Left scrotum:
Seen bowel filling the left scrotum
Left testis looks unclear
Incidental finding at right ingunal regio:
Seen Vesica urinaria at right inguinal dextra regio
Conclution:
Support the sign of hernia scrotalis bilateral

Working Diagnosis
Obsv. Scrotal Mass e.c susp Inguinal Bladder
Interna

Management
Consult to digestive surgery:
Obsv. Vital sign
Co. Urology
Consult to urology:
Antibiotic
H2 Blocker
Analgetic
Pro uretrocystography
If cant urinate, DC cateter small caliber (RF)
Join treatment with digestive

4. Mr. Rusbani 50 yo/ December 22nd

2014 at 21.00
Chief Complain : discharge from
operation site
History :
since 7 days ago before admission, pts
complain about his urin and blood comes
out from operation site. 15 days before
admission, because he had BPH pts got
prostatectomy treatment at
Balangan
hospital. Now, pts have complaining
about his scar from operation site and
swollen at his face and foot.

Physical Examination

Compos Mentis
BP: 130/90mmhg
P: 108 tpm
RR: 24 tpm
T: 36, C

CVA

I : wound (-/-), hematome (-/-)

P : mass (-/-), tenderness (-/-)
Flank Area
I : mass (-/-), hematome (-/-), wound (-/-)
P: mass , tenderness (-/-)
Suprapubic
I: improminent urinary bladder, wound (-), hematome (-), mass
(-)
P : tenderness (+)
Genitalia
OUE : bloody discharge (-), edema (-), stone (-)
54

Clinical picture

a/r abdomen
I:: Ascites, wound post op
is wet, pus (+),
A: P: Pain (+),
Urine (+)
Palpable pain (+) a/r
suprapubic
Release pain (-)
P: Shifting dullnes (+)

LABORATORY FINDING

13,5Result

HEMATOLOGY
Parameter

Normal Value

December 22nd, 2014

Hemoglobin

7.8

14,0-18,0 g/dl

Lekosit

1.3

4,0-10,5 ribu/ul

Eritrosit

2.85

4,5-6,0 juta/ul

Hematokrit

24.1

42-52 vol %

Trombosit

103

150-450 ribu/ul

MCV

84,6

80-97 fl

MCH

27,3

27-32 pg

MCHC

32,3

32-38 %

Ureum

151

10-50 g/dL

Creatinin

2.1

0,7-1,4 mg/dL

GDS
SGOT/ SGPT

161
28/19

<200 mg/dL
0-45 U/I

59

PEMERIKSAAN

HASIL

RUJUKAN

SATUAN

Albumin

2.6

3.5-5.5

g/dl

60

Working Diagnosis
Fistula
Vesico
Cutaneus
post
open
prostatectomy + Anemia + Trombositopeni +
hypoalbunemia+ severe Sepsis

Management

Co Urology surgery:
Observation of Vital Sign
O2 3-4 rpm
IVFD Rl : D5 3:1 2000cc/day
Antibiotic
Analgetic
H2 Blocker
Blood Transfution 2 kolf
Albumin injection

6. Mr. Samsul
Bahri
45 yo/ December 22nd
Suri/
50 Yo/1-11-55-77
2014 at 22.30
Chief Complain : Had an accident (?)
History :
an hours before admission, pts rode his motorcycle
with his wife. They were suddenly got crushed with
another motocycle from the back. He and his wife
fell to the ground. He wore a helmet, but still injury
his forehead. There were no history of bleeding from
ears, mouth and nose. Fainting (-), vomit (-). Pts then
brought to Ulin general hospital by his family for
further treatment.

Primary Survey

Clear (-), snoring (-), gurgling(+), stridor (-)

Clear, RR : 24 tpm, simetric respiratory movement, VBS simetry,

Pulse 88 tpm, reguler, lift strong, the extremities warm

BP: 130/80 mmHg

GCS E4V5M6, P 3mm/3mm, light reflex +/+, parese -/-

Rh -/-, wh -/-

Secondary Survey
Head/Neck

Chest

Abdomen

Extremities

Eyes : anemic conjungtivae (-/-), icteric sclerae (-/-)

Nose : epitaksis (-)
Ear : otohargia (-), battle sign (-)
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-), cephal
hematom (-)
I : symmetric respiratory movement
P : symmetric VF (+/+)
P : sonor at all lung
A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)
I : distention (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,
rebound tenderness (-)
P : Tympani

Warm, parese (-/-), see status localized

(-)

(-)

(-)

12 hour before admission

On the Road

Clinical Pictures

Localized Status
a/r peri orbita dextra
L: edem (+), deformity (-), wound (+), size
diameter 2 cm, base wound bone (+), active
bleeding (-)
F: tenderness (+), crepitation (-), pain (+)

Localized Status
a/rfemur dextra
L: edem (+), deformity (-), wound (+),
size diameter 5 cm, base wound bone
(+)
F: tenderness (+), crepitation (-), pain
(+)
M: ROM limited due to pain

Post hecting

Skull X-ray

Thorax X-ray

Knee X-ray

Working Diagnosis
CKR + Vulnus laxceratum a/r periorbita dextra,
genu dextra

Management
IVFD RL
Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker

7. Mr. Mulyana 55 yo/ December 22nd

2014 at 22.55
Chief Complain : Cant urinate
History :
2 days before admission, pts complaint that he
cant urinate. Then pts seek treatment to Tanah
Bumbu. Because he cant get to wore urin
cateter, he got open cystotomy. Pts
complaining about having difficulty to urinate
since 5 days before admission. The pain from
cant urinate continously increase day after
day. History of stone voiding (-), sandy voiding
(-). Pts had history of blood voiding.

Physical Examination

Compos Mentis
BP: 130/90mmhg
P: 10 tpm
RR: 24 tpm
T: 36, C

CVA

I : wound (-/-), hematome (-/-)

P : mass (-/-), tenderness (-/-)
Flank Area
I : mass (-/-), hematome (-/-), wound (-/-)
P: mass , tenderness (-/-)
Suprapubic
I: improminent urinary bladder, wound (-), hematome (-), mass
(-)
P : tenderness (+)
Genitalia
OUE : bloody discharge (-), edema (-), stone (-)
78

LABORATORY FINDING

13,5Result

HEMATOLOGY
Parameter

Normal Value

December 19nd, 2014

Hemoglobin

12.1

14,0-18,0 g/dl

Lekosit

17300

4,0-10,5 ribu/ul

Eritrosit

4,76

4,5-6,0 juta/ul

Hematokrit

36

42-52 vol %

Trombosit

213

150-450 ribu/ul

Ureum

49

10-50 g/dL

Creatinin

0,7-1,4 mg/dL

GDS
SGOT/ SGPT

134
17/17

<200 mg/dL
0-45 U/I

Albumin

4.49

PT

4 minute

APTT

2 minute 10 second

80

PEMERIKSAAN

HASIL

RUJUKAN

PT

4
1,08
11,4
210
26,1

9,9-13,5 dtk

INR
Control Normal PT
APTT
Control Normal APTT

22,2-37 dtk

SATUAN

U/I

81

USG

Expertise
Conclusion:
1. Pelvicocaliectasis Ren Bilateral
2. Cystitis
3. Susp. Distal Ureter Calculy and diverticel at
left lateral vesikurinaria
4. Hyperplasia Prostat

Urine out put

Cystostomy bag

Working Diagnosis
Post Open Cystotomy ec Susp Strictur Uretra
Posterior

Management
IV Line
Antibiotic
analgetic
H2 blocker
Co Urologist surgery:
Pro BVUC

8. Mr. SamuelSuri/
Salodong
31 yo/ December 23rd
50 Yo/1-11-55-77
2014 at 02.15
Chief Complain : pain at right leg
History :
3 days before admission, pts fell from stair. He
dislocate his foot cause it used to support his body.
Pts complain pain and swelling at his leg. History of
fainting (-), bleeding at his ears, nose, and mouth (-)
Pts then brought to Ulin general hospital by his
family for further treatment.

Primary Survey

Clear (-), snoring (-), gurgling(+), stridor (-)

Clear, RR : 24 tpm, simetric respiratory movement, VBS simetry,

Pulse 86 tpm, reguler, lift strong, the extremities warm

BP: 130/80 mmHg

GCS E4V5M6, P 3mm/3mm, light reflex +/+, parese +/-

Rh -/-, wh -/-

Secondary Survey
Head/Neck

Chest

Abdomen

Extremities

Eyes : anemic conjungtivae (-/-), icteric sclerae (-/-)

Nose : epitaksis (-)
Ear : otohargia (-), battle sign (-)
Mouth : wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-), cephal
hematom (-)
I : symmetric respiratory movement
P : symmetric VF (+/+)
P : sonor at all lung
A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)
I : distention (-)
A : normal Bowel sound
P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) ,
rebound tenderness (-)
P : Tympani

Warm, parese (+/-), see status localized

(-)

(-)

(-)

Clinical Pictures

Localized Status
a/r cruris dextra et pedis dextra
L: edem (+), deformity (+), wound (-),
angulation (+)
F: tenderness (+), crepitation (+), pain (+)
M: ROM limited

Cruris X-ray

Pedis X-ray

Working Diagnosis
Closed fracture cruris 1/3 distal intra artikular
cominutive displaced dextra

Management
Consult to Ortopaedy
Posterior slab
Analgetic
H2 Blocker
Pro ORIF elective