Emergency Case

Report
April 1st 2015

Resident on Duty : dr. Alma

Minor Surgery

:-

Digestive Surgery

:1

Thorax Cardiovasc1lar Surgery

Plastic

Surgery

:-

Urology Surgery

:-

Neurosurgery

:4

Pediatric Surgery

:-

Oncology Surgery

:-

Orthopaedy
Total

:1
:7

:1

No

Identity

Mr.
Sugiono/58
y.o/1.14.59.
17

Admission
to E.R.
April 1
2015

Diagnosis
Moderate head
Injury GCS 9
+ ICH at left
temporal region15
cc + ICH at left
occipital region 5
cc + SDH at
temporal region +
SAH falk cerebri
with midline shift to
the right 1.2 cm

Treatment / Planning
Vital sign obs.
Head up 30d
Oxigenation
IVFD NS
Antibiotic
Analgetic
H2blocker
Manitol program
Consul neurosurgeon
Pro craniotomy
Evacuation
Patient discharge by
request

No

Identity

Mr. Yunidar/
34 y.o/
1.14.51.75

Admission
to E.R.
April 1,
2015

Diagnosis

Treatment / Planning

Severe head
injury GCS 6
+ SDH on
going
bleeding at
right
temporopariet
al region >
1cm thickness
+ ICH 12cc at
right temporal
region + SAH
+ susp Skull
base fracture
left median
fossa

vital sign obs.

Head up
oxigenation
IVFD NS
Antibiotic
Analgetic
H2blocker
Complete blood count
CT Scan
Co Neurosurgeon :
Pro Craniotomy
evacuation
GCS 3 --> DNR

No

Identity

Ch. Nia/ 7
y.o/
1.14 51 89

Admission
to E.R.
April 1,
2015

Diagnosis
Mild head Injury
GCS 15 + SDH
minimal at left
temporal region
(Post hospital
treatment day 5)

Treatment / Planning
vital sign obs.
Co neurosurgeon
Analgetic
Became outpatient
clinic

No

Identity

Mr. Ihya/ 17
y.o/
1.14.59.19

Admission
to E.R.
April 1,
2015

Diagnosis

Treatment / Planning

Localized peritonitis Antibiotic

d.t perforated
H2Blocker
appendicitis
Analgetic
Consul to digestif
surgeon
Pro appendictomy cito

No

Identity

5.

Ch. Ridho
P/ 6 y.o/
1.14.59.41

Admission
to E.R.
April 1,
2015

Diagnosis
Head Mild Inj GCS
14 +cerebral
Contusion at left
frontal region +
susp. Skull base
fracture Anterior
fossa

Treatment / Planning
Vital sign obs.
IVFD NS
Oxigenation
Antibiotic
Analgetic
H2blocker
Co neuro surgeon
Conservatif
treatement

No

Identity

6.

Ch. Nurul/ 3
y.o/
1.14.54.44

Admission
to E.R.
April 1,
2015

Diagnosis

Treatment / Planning

Closed fracture of
the right femur
transverse
displaced

vital sign obs.

IVFD RL
Antibiotic
Analgetic
H2blocker
Complete blood count
Co orthopedic
Skin traction
Pro spica Casting in
GA

No

Identity

7.

Mr.
Abdullah/
24 y.o/
1.14.44.49

Admission
to E.R.
April 1,
2015

Diagnosis
Obs blunt Chest
Trauma + left
pnemothorax and
lung contusion

Treatment / Planning
vital sign obs.
O2 NRM
IVFD
Antibiotic
Analgetic
H2blocker
USG Fast clear
Co TKV dept
Pro CTT

Mr. Sugiono/58 y.o/1.14.59.17

April 1, 2015
Chief Complain : decreased conciousness
History :
2 days before admission, patient had traffic

accident with motorcycle. The patient was lost

balanced and fall, Then patient head hit the
road. Helm (-), History of unconsciousness
(+), vomit (+), Ear/nose/throat bleeding
(+/-/-). The patient was riding alone, no
history of drunk before riding. After accident
the atient was brought to plaihari hospital and
got IVFD. Patient was refered to RSUD Ulin
from RS Pleaihari for further treatment.

Primary Survey

A
B

Clear

Clear, RR : 24x/mnt, simetry respiratory movement,

VBS simmetry, retraction (-/-)

GCS E3V5M3, Pupil anisokor 3mm/6mm, RC +/+

Pulse 90/mt,reguler, lift strong, the extremities warm

BP: 130/90 mmHg

Head/Nec
k

Eyes : anemic conjunctiva (-) icteric sclera (-)

Neck : Lymph nodes enlargement (-), JVP enhancement (-),
Periorbital edema a/r periorbital dextra
Battle sign (-) rhinorea (-) Othorea (-/+)

General Status
Chest

Abdomen

Extremitie
s

I : Symmetric respiratory movement, no retraction

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

I : Wound (-), distension (-),

A : Bowel sound (+) normal
P : mass palpable (-), pain (-)
P : Tymphani, CVA pain -/-

Warm (+/+), CRT < 2,

Clinical
picture

Local Status
Right Periorbital Edema +
Right Ottorhagia + Hallo test +
Battle sign
Racoon eye
Rinnorhagia
Maxilofacial : within normal Limit

X-Ray

CT Scan

laboratorium
Hb

11.6

14.00-18.00

Leukosit

15.5

4.0-10.5

Trombosit

239

150-450

Hematokrit

34.1

42.00-52.00

PT

10.4

9.9-13.5

APTT

25,3

22.2-37.0

SGOT

39

0-46

SGPT

21

0-45

Ureum

36

10-50

Creatinin

0,6

0.7-1.4

Working Diagnosis
Moderate head Injury GCS 9
+ ICH at left temporal region15 cc + ICH at left occipital
region 5 cc + SDH at temporal region + SAH falk cerebri
with midline shift to the right 1.2 cm

Management
Vital sign obs.
Head up 30d
oxigenation
Antibiotic
Analgetic
H2blocker
Manitol program
Consul neurosurgeon :
Pro craniotomy Evakuasi

Patient discharge by request

Mr. Yunidar/ 60 y.o/ 1.14.59.26

April 1,2015
Chief Complain : decreased conciousness
History :
5 hours before admission, patient had traffic

accident with motorcycle in gambut area.the

patient was riding alone then suddenly
someone robbed her and she was fallen from
the bike. Her head hit the road. History of
unconciousness (+), vomit (+), Ear/nose/throat
bleeding (+/-/-). Patient was refered to RSUD
Ulin from Gambut Puskesmas.

Primary Survey

A
B

Gurgling (+) , Suction Clear

Vommiting (+), Suction Clear

Clear, RR : 30x/mnt, simetry respiratory movement,

VBS simmetry, retraction (-/-)

GCS E1V4M1, Pupil isokor 3mm/3mm

Pulse 98/mt,reguler, lift strong, the extremities warm

BP: 100/60 mmHg

Head/Nec
k

Eyes : anemic conjunctiva (-) icteric sclera (-)

Neck : Lymph nodes enlargement (-), JVP enhancement (-),
Raccon eye (-/-) , Battle sign (-) rhinorea (-) Othorea (-/+)

General Status
Chest

Abdomen

Extremitie
s

I : Symmetric respiratory movement, no retraction

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

I : Wound (-), distension (+),

A : Bowel sound (+) normal
P : mass palpable (-), pain (-)
P : Tymphani, CVA pain -/-

Warm (+/+), CRT < 2,

Left elbow : edema (+), deformity (+)

Local status
Racoon eye
Battle sign
Ottorhagia -/+ hallo test +
Rinnorhagia
Sutured wound at left temporal region

Elbow :
L : edema + deformity
F : false movement crepitationM : N/A

X-Ray

CT-Scan

laboratorium
Hb

8.8

14.00-18.00

Leukosit

23.6

4.0-10.5

Trombosit

313

150-450

Hematokrit

27,3

42.00-52.00

PT

9.9

9.9-13.5

APTT

18.1

22.2-37.0

SGOT

50

0-46

SGPT

27

0-45

Ureum

34

10-50

Creatinin

0,9

0.7-1.4

Working Diagnosis
Severe head injury GCS 6 + SDH on going
bleeding at right temporoparietal region >
1cm thickness + ICH 12cc at right temporal
region + SAH + susp Skull base fracture left
median fossa

Management
vital sign obs.
Head up
oxigenation
IVFD NS
Antibiotic
Analgetic
H2blocker
Complete blood count
CT Scan
Co Neurosurgeon :
Pro Craniotomy evacuation
GCS 3 --> DNR

Ch. Nia/ 7 y.o/1.14 51 89

April 1,2015
Chif complaint : head ache
History : 4 daybefore hospitalized

the
patient was crossing the road then
suddenly she was hit by motorcycle and
felt. Fainted (+), bleeding from ear, nose,
and mouth (-), vomitting (+). Patient was
referred to RS Pulang Pisau and refered to
RSUD Ulin for further treatment.

Primary Survey

A
B

Clear

Clear, RR : 20x/mnt, simetry respiratory movement,

VBS simmetry, retraction (-/-)

Pulse 78/mt,reguler, lift strong, the extremities warm

GCS E4V5M6, Pupil isokor 3mm/3mm, RC +/+

Head/Nec
k

Eyes : anemic conjunctiva (-) icteric sclera (-)

Neck : Lymph nodes enlargement (-), JVP enhancement (-),
Raccon eye (-/-) , Battle sign (-) rhinorea (-) Othorea (-/-)

General Status
Chest

Abdomen

Extremitie
s

I : Symmetric respiratory movement, no retraction

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

I : Wound (-), distension (+),

A : Bowel sound (+) normal
P : mass palpable (-), pain (-)
P : Tymphani, CVA pain -/-

Warm (+/+), CRT < 2,

laboratorium
Hb

12.1

14.00-18.00

Leukosit

14.8

4.0-10.5

Trombosit

342

150-450

Hematokrit

39

42.00-52.00

Clinical Picture

CT-Scan

Working Diagnosis
Mild head Injury GCS 15 + SDH minimal at left temporal
region
(Post hospital treatment day 5)

Management
Vital sign obs.
Co neurosurgeon
Analgetic
Became outpatient clinic

Mr. Ihya/ 17 y.o/ 1.14.51.89

April 1,2015

Chief Complain : pain on right stomach

History :

2 days before admission patient complained

right lower abdominal pain. Fever (+), nausea
(+) vommiting (-). Urinating and defecating
was within normal limit. At the beginning the
pain was from epigastrium and then refered
to right lower stomatch. Patient came to Ulin
for futher treatment.

Vital Sign
TD: 110/70
HR: 90
RR :26
T: 37,4

General Status
Head/Neck

Eyes : anemic conjunctiva (-) icteric sclera (-)

Neck : Lymph nodes enlargement (-), JVP enhancement (-),

Chest

I : Symmetric respiratory movement, no retraction

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

Abdomen

I : Wound (-), distension (-)

A : Bowel sound (+) normal
P : mass palpable (-), pain (-), Mc. Burney sign (+)
P : Tymphani, CVA pain -/-

Extremitie
s

RT

Warm ( +/+) Edem (-/-)

TSA strong, ampula not collapse,

smooth mucose, pain (+) regio
9-11, feses (+), blood (-)

Clinical picture

X-Ray

laboratorium
Hb

14.1

14.00-18.00

Leukosit

17.0

4.0-10.5

Trombosit

217

150-450

Hematokrit

40.8

42.00-52.00

PT

12.2

9.9-13.5

APTT

33.9

22.2-37.0

Ureum

20

10-50

Creatinin

1,2

0.7-1.4

Working Diagnosis
Localized peritonitis d.t perforated
appendicitis

Management
Antibiotic
H2Blocker
Analgetic
Consult to digestif surgeon
Pro appendictomy cito

Ch. Ridho P/ 6 y.o/ 1.14.59.41

April 1,2015
Chief Complain : head ache
History :
5 hours before admission, patient had traffic

accident at backseat of motorcycle. Then,

patient fell to the front and his head hit the
road. History of unconsciousness (+), vomit
(-), Ear/nose/throat bleeding (-/+/-). Patient
was refered to RSUD Ulin from RS Anshari
Saleh.

Primary Survey

A
B

Clear

Clear, RR : 24x/mnt, simetry respiratory movement,

VBS simmetry, retraction (-/-)

Pulse 90/mt,reguler, lift strong, the extremities warm

GCS E4V5M6, Pupil anisokor 3mm/3mm, RC +/+

Head/Nec
k

Eyes : anemic conjunctiva (-) icteric sclera (-)

Neck : Lymph nodes enlargement (-), JVP enhancement (-),
Raccon eye (-/-) , Battle sign (-) rhinorea (-) Othorea (-/-)
Hematom ar frontal dextra 5 cm, tenderrness (+)

General Status
Chest

Abdomen

Extremitie
s

I : Symmetric respiratory movement, no retraction

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

I : Wound (-), distension (+),

A : Bowel sound (+) normal
P : mass palpable (-), pain (-)
P : Tymphani, CVA pain -/-

Warm (+/+), CRT < 2,

Clinical pictures

Local status
Frontal edema +
Racoon eye
Battle sign
Rinnnorhagia +
Ottorhagia
Maxilo facial : Edema at upper lip region

CT Scan

laboratorium
Hb

10,7

14.00-18.00

Leukosit

17.2

4.0-10.5

Trombosit

435

150-450

Hematokrit

33.2

42.00-52.00

SGOT

41

0-46

SGPT

14

0-45

Ureum

26

10-50

Creatinin

0.7

0.7-1.4

Working Diagnosis
Head Mild Inj GCS 14 +cerebral Contusion at left frontal
region + susp. Skull base fracture Anterior fossa

Management
Vital sign obs.
IVFD NS
Oxigenation
Antibiotic
Analgetic
H2blocker
Co neuro surgeon
Conservatif treatement

Ch. Nurul/ 3 y.o/ 1.14.54.44

April 1,2015
Chief Complain : pain in right lower thigh
History :

8 hours before admission, patient was

hit by motorcycle . Her right thigh was

crushed
by
tire.
History
of
unconsciousness
(-),
vomit
(-),
Ear/nose/throat bleeding (-/-/-). Now
the patient feel pain at her right tight.
Patient was refered to RSUD Ulin from
RS Rantau for further treatment.

Primary Survey

A
B

Clear

Clear, RR : 26x/mnt, simetry respiratory movement,

VBS simmetry, retraction (-/-)

Pulse 92/mt,reguler, lift strong, the extremities warm

GCS 15, Pupil anisokor 3mm/3mm, RC +/+

Head/Nec
k

Eyes : anemic conjunctiva (-) icteric sclera (-)

Neck : Lymph nodes enlargement (-), JVP enhancement (-),
Raccon eye (-/-) , Battle sign (-) rhinorea (-) Othorea (-/-)

General Status
Chest

Abdomen

Extremitie
s

I : Symmetric respiratory movement, no retraction

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

I : Wound (-), distension (+),

A : Bowel sound (+) normal
P : mass palpable (-), pain (-)
P : Tymphani, CVA pain -/-

Warm (+/+), CRT < 2

Ar femur dextra : edema (+), deformity (+), tenderness
(+), false movement (+)

Clinical pictures

Local Status
L : Edema + Deformity +
F : Tenderness + false movement +
M : Limited due to pain

X-Ray

April 1, 2015
Result

referance

hb

9.2

14.00-18.00

Leukosit

10,3

4.0-10.5

Trombosit

250

150-450

SGOT

98

0-46

SGPT

34

0-45

Natrium

139.8

135-146

kalium

4.3

3.4-5.4

chlorida

104.8

95-100

Laboratoriu
m

Working Diagnosis
Closed fracture of the right femur transverse displaced

Management
vital sign obs.
IVFD RL
Antibiotic
Analgetic
H2blocker
Complete blood count
Co orthopedic
Skin traction
Pro spica Casting in GA

Mr. Abdullah/ 24 y.o/

1.14.44.49

April 1,2015
Chif complaint: Shortness of breath
History : 20 hours before hospitalized the

patient was riding motorcycle, he crashed and

he fell with his body first. He was helped by
people and brought to home and then he got
massage. Unconscious (-) Bleeding on ears (-),
nose (-), mouth (-). Patient was brought to
RSUD Ulin for further treatment.

Primary Survey

A
B

Clear

Clear, RR : 26x/mnt, simetry respiratory movement,

VBS left < right , retraction (-/-)

Pulse 92/mt,reguler, lift strong, the extremities warm

GCS 15, Pupil anisokor 3mm/3mm, RC +/+

Head/Nec
k

Eyes : anemic conjunctiva (-) icteric sclera (-)

Neck : Lymph nodes enlargement (-), JVP enhancement (-) laceration
(-),
Raccon eye (-/-) , Battle sign (-) rhinorea (-) Othorea (-/-)

General Status
Chest

Abdomen

Extremitie
s

I : Symmetric respiratory movement, excoriation

hemithorax dextra
P : Symmetric VF
P : Sonor, dull at left basal pulmo
A : VBS left < right, rhonchi (-), no wheezing
I : Wound (-), distension (+), laceration (+)
A : Bowel sound (+) normal
P : mass palpable (-), pain (-)
P : Tymphani, CVA pain -/-

Warm (+/+), CRT < 2

April 1, 2015
Result

referance

hb

16.5

14.00-18.00

Leukosit

16,8

4.0-10.5

Trombosit

248

150-450

SGOT

133

0-46

SGPT

123

0-45

Ureum

15

10-50

Creatinin

1.0

0.7-1.4

PT

9.2

9.9-13.5

APTT

26.2

22.2-37.0

Laboratoriu
m

Clinical Pictures

Local Status
Injury at right Upper quadrant abdomen

Tenderness defans muscular VBS left < right

X-Ray

Working Diagnosis
Obs blunt Chest Trauma + left pnemothorax and lung
contusion

Management
vital sign obs.
O2 NRM
IVFD
Antibiotic
Analgetic
H2blocker
USG Fast clear
Co TKV dept
Pro CTT