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Emergency Case

ReportApril 9th-10th 2013

Resident on Duty : dr. Alex

Chief Co-Assistant : Hendra

Team :

Arif ZN, Diny, Rachma, Aina

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Minor Surgery :

Digestive Surgery :

Thorax Cardiovascular Surgery :

Plastic Surgery :

Urology Surgery :

Neurosurgery :

Pediatric Surgery :

Oncology Surgery :

Orthopaedi :

Total :

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No. Identity Admission

to E.R.

Diagnosis Treatment /

Planning

1 Mr. M. Yusran /

53 yo

April 9th 2013

at 14.15

2. Mr. Khairudin /

32 yo

April 9th 2013

at 16.55

3. Mr. Sunaryo /

60 yo

April 9th 2013

at 17.10

4. An. Ali Yasir /8 yo

April 9th 2013at 18.00

5. Mrs. Ramsidah

/ 51 th

April 9th 2013

at 18.35

Patients List

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Patients ListNo. Identity Admission

to E.R.

Diagnosis Treatment /

Planning

5. Mr. Hadarani /

71 yo

April 9th 2013

at 23.38

6. Mr. Andre /24 yo

April 9th

2013

7. Mr. Timotius /

32 yo

April 9th 2013

8. Mrs. Thalha /

37 yoApril 9th 2013

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1. Mr. M. Yusran/ 53 yo/ April 9th 2013 at 14.15

Chief Complain : Painful when urinate

History :

These complaints experienced during the one year.

Patients are often control to the doctor and wasdiagnosed as BPH. When patients want surgery it was

discovered that the patient was suspected Prostate Ca

and do the biopsy. The patient was hospitalized for 1

month at Kapuas Hospital and referred to Ulin general

hospital for further treatment. Current patient complaintis pain while urinating, urine comes out red and lumpy.

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Physical Examination

Alert

Vital sign :

BP = 100/60 mmHg PR = 88 bpm

RR = 22 bpm

T = 38,0C

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Eyes : No anemic conjunctivae, icteric sclerae (-),

Nose : No epistaxis

Mouth : Wet mucosa

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

Head/Neck

I : Simmetric respiratory movement, no retraction P : Simmetric VF

P : Sonor at all lung fields

A : Simmetric VBS, no rhonchi, no wheezing

Chest

I : Distention (-)

A : Bowel sound (+) N

P : Liver/spleen/kidney not palpable, mass not palpable,

tenderness (-) P : Tymphani

Abdomen

Warm, no oedema, no pareseExtremities

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Urologic Status

CVA

I : mass (-/-), hematom (-/-) Pa : tenderness (-/-)

Pe : pain (+/-)

Flank Area

I : mass (-/-), hematoma (-/-),

Pa : tenderness (-/-)

SuprapubiC

I : mass (-), hematoma (-)

Pa: tenderness (-)

Genitalia

OUE : bloody discharge (-)

Penis: edema (-), hematoma (-) tenderness (-)

Skrotum: mass (-), testis (+/+)

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DRE

I : Haemorrhoid (-), laceration (-) P : Sphincter ani muscle strong

Smooth mucosa

Ampulla wasnt collapse

Mass (-)

Tenderness (-)

Prostat: Touched, hard consistence

Surface not flat Mediana sulci not palpable

Upper pole not easy to touch

Tenderness (-)

Handscon : feces (+), blood (-)

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Laboratory Finding

Haematology

Haemoglobin : 9.1 g/dl

RBC : 3.28

WBC : 14.100

Hematocrit : 28.8

Platelet : 452.000

Chemistry

BSR : 148

PT / APTT : 13.1 / 35.8

OT/ PT : 180 / 188

Ureum : 41

Creatinin : 0.9

Sodium : 138.5

Potassium : 3.9

Chloride : 99.1

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Laboratory Finding

Urinalisa

Color : Yellow

BJ : 1000

Ph : 7.0

Protein-Albumin : 1+

Occult Blood : 3+

Urobilinogen : 0.2

Leukosit : 3+

Sedimen

Leukosit : many

Erythrosit : many

Selinder : negative

Epithel : 1+

Bactery : 1+

Crystal : negative

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Clinical Picture

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Clinical Picture

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Urologi + USG Prostat

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Working Diagnosis

Retensio Urine e.c. Susp. Ca. Prostat

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Management

Co/ to Urology surgery:

Aminofusin 30 tpm

Ceftriaxon 2x1

Tramadol 2x1

Ranitidin 2x1

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2. Mr. Khairudin/ 32 yo/ April 9th 2013 at 16.55

Chief Complain :

History :

4 hours before admission, patient was inserted catheter

urine because he was complained about cant urinate. 2hours before admission, the patient was pull out the

catheter. The patient complained about painful from

genital and blood was out from his penis. Patient is

patient with schizophrenia history and treated in

Sambang Lihum hospital.

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Alert

Vital sign :

BP = 110/70 mmHg

PR = 80 bpm

RR = 21 bpm

T = 36,6C

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Nose : No epistaxis

Mouth : Wet mucosa


Head/Neck

I : Simmetric respiratory movement, no retraction

P : Simmetric VF



Chest

I : Distention (-)




Abdomen


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Urologic Status

CVA


Pe : pain (+/-)

Flank Area



SuprapubiC


Pa: tenderness (-)

Genitalia




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DRE

I : Haemorrhoid (-), laceration (-) P : Sphincter ani muscle strong

Smooth mucosa


Mass (-) Tenderness (-)

Prostat: Touched, chewy consistence

Nodul (-) Mediana sulci palpable


Tenderness (-)


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Clinical Picture

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Working Diagnosis

Susp. Laseration Uretra e.c DD Ruptur

Uretra

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Management

Co/ to Urology surgery :

Discharge by permission

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3. Mr. Sunaryo/ 60 yo/ April 9th 2013 at 17.10

Chief Complain :

History :

1 days before admission, patient complained cant urinate. He was

complained too about pain at the bilateral waist. The patient was

inserted catheter urine in Marabahan Hospital then referred to Ulin

General Hospital.

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Alert

Vital sign :

BP = 130/80 mmHg

PR = 84 bpm

RR = 20 bpm

T = 36,6C

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Nose : No epistaxis

Mouth : Wet mucosa


Head/Neck


P : Simmetric VF



Chest

I : Distention (-)




Abdomen


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Urologic Status

CVA


Pe : pain (+/-)

Flank Area



SuprapubiC


Pa: tenderness (-)

Genitalia




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DRE

I : haemorrhoid (-), laceration (-)

P : Sphincter ani muscle strong

Smooth mucosa



Prostat: Touched, chewy consistence

Nodul (-)

Mediana sulci palpable


Tenderness (-)


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Laboratory Finding

Haematology


RBC : 3.67

WBC : 8000

Hematocrit : 32.5

Platelet : 190.000

Chemistry

BSR : 148

PT / APTT : 11.8 / 27.2

OT / PT : 26 / 15

Ureum : 96

Creatinin : 1.3

Sodium : 136.3

Potassium : 3.0

Chloride : 100.4

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Laboratory Finding

Urinalisa

Color : Green

BJ : 1.020

Ph : 5.5


Occult Blood : 3+

Urobilinogen : 0.2

Leukosit : 2+

Sedimen

Leukosit : 40-50

Erythrosit : 30-50

Selinder : negative

Epithel : 1+

Bactery : negative

Crystal : negative

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Clinical Picture

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Clinical Picture

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X-Ray

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Working Diagnosis

Retensi Urin e.c. Vesicolitiasis

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Management

Co/ to Urology surgery:

IVFD RL

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4. Child Ali Yasir/ 8 yo / April 3th 2013 at 18.00

Chief Complain : Headache

History :

+ 5 days before admissionthe patient had a traffic accident.

Patient was riding the bicycle and hit by a motorcycle.History of unconsciousness (+). vomiting (-), bleeding

nouse / ear / mouth (-/-/-). Headache (+). The patient was

brought to Kapuas hospital, then reffered to Ulin general

hospital.

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Primary Survey

Clear, snoring (-), gurgling (-), c-spinecontrol (+)A

Clear, RR=20 bpm, symmetric

respiratory movement, symmetricVBSB

BP : 100/70 mmHg Pulse rate : 80 bpm, reguler, strong

lifted, CRT < 2 sec.C

GCS E4V5M6, round and symmetricpupils diameter (2mm/2m), light

reflexes (+/+), no paralysisD

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A

-

M -

P -

L -

E Ashphalt

S d

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Secondary survey

Eye : anemic conjunctivae (-/-), icteric sclera (-/-)

Mouth : Wet mucose

Neck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)

Local status

Head/Neck

I : symmetric respiratory movement, retraction (-)

P : symmetric VF P : Sonor in all lung field

A : symmetric VBS, Rh (-/-), Wh (-/-)Chest

I : wound (-), distension (-), hematoma (-)

A : Normal bowel sound

P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrantsAbdomen

warm, edema (-), paralysis (-)Extremities

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Clinical Picture

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CT-Scan

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Laboratory Finding

Haematology


RBC : 3.82

WBC : 8800

Hematocrit : 31.3

Platelet : 305.000

Chemistry

BSR : 116

PT / APTT : 11.9 / 23.2

OT / PT : 20 / 9

Ureum : 33

Creatinin : 0.4

Sodium : 139.9

Potassium : 4.2

Chloride : 108.2

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Working Diagnosis

EDH a/r Temporoparietal Dextra + SDHa/r Temporoparietal Sinistra

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Management

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5. Mrs. Ramsidah/ 51 yo/ April 9th 2013 at 18.35

Chief Complain : Pain at the right waist area

History :

2 days before admission, patient experienced pain at the right waist

area. The pain came intermittent, moderate pain (+), the pain camecontinuously. Nausea (-), vomiting (+), anorexia (-), fever (+).

History of epigastric pain (-). Previous similar pain (-), previous

abdominal surgery (-). Bowels (N), urinate (N). Because the

complaint, patient was brought to Ulin General Hospital.

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Alert

Vital sign :

BP = 170/100 mmHg

PR = 80 bpm

RR = 22 bpm

T = 36,6C

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Nose : No epistaxis

Mouth : Wet mucosa


Head/Neck


P : Simmetric VF P : Sonor at all lung fields


Chest

I : Distention (-)


P : Liver/spleen/kidney not palpable, mass not palpable,tenderness (-)

P : Tymphani

Abdomen


DRE

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DRE

I : Haemorrhoid (-), laceration (-) P :

Sphincter ani muscle strong

Smooth mucosa Ampulla wasnt collapse

Mass (-)

Tenderness (-) Handscon : feces (+), blood (-)

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Alvarado Score

M0 A1 N2 T0 R0 E0 L S

Psoas Sign (+)

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Laboratory Finding

Haematology


RBC : 5.17

WBC : 15.600

Hematocrit : 38.3

Platelet : 248.000

Chemistry

BSR : 91

PT / APTT : 14.6 / 29.3

OT / PT : 13 / 11

Ureum : 34

Creatinin : 1.4

Sodium : 141.0

Potassium : 3.7

Chloride : 110.8

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Laboratory Finding

Urinalisa

Color : Yellow

BJ : 1.025

Ph : 6.0

Keton : 1+


Occult Blood : 1+

Urobilinogen : 0.2

Leukosit : 2+

Sedimen

Leukosit : 15-30

Erythrosit : 3-5

Selinder : negative

Epithel : 2+

Bactery : negative

Crystal : negative

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Clinical Picture

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X-Ray

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Working Diagnosis

Nephrolytiasis Bilateral DD App

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Management

Co/ to Urology surgery: IVFD RL 20 tpm

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6. Mr. Hadarani/ 71 yo/ April 9th 2013 at 23.38

Chief Complain :

History :

KU : Nyeri pinggang kanan

Pasien mengeluhkan nyeri pinggang sejak + 1 bulanSMRS. Nyeri dirasakan terus menerus tapi tidak menjalar

dan tidak berkurang dengan perubahan posisi. Pasien juga

mengeluhkan adanya benjolan sebesar bola tenis, keras

dan terasa nyeri. Pasien juga mengeluhkan sulit kencing.

Riwayat kencing batu (+) 6 th lalu,kencing darah (-).

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Alert

Vital sign :

BP = mmHg

PR = bpm

RR = bpm

T = C

Ph i l E i i

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Nose : No epistaxis

Mouth : Wet mucosa


Head/Neck


P : Simmetric VF P : Sonor at all lung fields


Chest

I : Distention (-)


P : Liver/spleen/kidney not palpable, mass not palpable,tenderness (-)

P : Tymphani

Abdomen


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Urologic Status

CVA


Pe : pain (+/-)

Flank Area



SuprapubiC


Pa: tenderness (-)

Genitalia




DRE

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DRE

I : Haemorrhoid (-), laceration (-)

P : Sphincter ani muscle strong

Smooth mucosa



Prostat: Touched, hard consistence

Surface not flat

Mediana sulci not palpable


Tenderness (-)


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Laboratory Finding

Haematology

Haemoglobin : g/dl

RBC :

WBC :

Hematocrit :

Platelet :

Chemistry

BSR :

PT / APTT : /

OT/ PT : /

Ureum :

Creatinin :

Sodium :

Potassium :

Chloride :

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Laboratory Finding

Urinalisa

Color : Yellow

BJ : 1000

Ph : 7.0


Occult Blood : 3+

Urobilinogen : 0.2

Leukosit : 3+

Sedimen

Leukosit : many

Erythrosit : many

Selinder : negative

Epithel : 1+

Bactery : 1+

Crystal : negative

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Clinical Picture

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X-Ray

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Working Diagnosis

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Management

1. MR 9-10 April 2013.pptx

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