MR 20-12-14

8/10/2019 MR 20-12-14

1/131

Emergency Case Report

2014 20-21

TH

December

Resident on Duty : dr. Yan AdityaChief Co-Assistant : Erina

Team :

Endah, Mira, Firdha, Dyah, Bimo, Ady

8/10/2019 MR 20-12-14

2/131

Minor Surgery : -

Digestive Surgery : 1

Thorax Cardiovascular Surgery : -

Plastic Surgery : -

Urology Surgery : -

Neurosurgery : 5

Pediatric Surgery : -

Oncology Surgery : 1

Orthopaedy : 3

Total : 10

8/10/2019 MR 20-12-14

3/131

No IdentityAdmission to

E.R.Diagnosis Treatment / Planning

1 Mr. Anang Rusdi/

63 y.o/ 1.13.25.81

20th

December

2014/ 15.00

Bloody feces due to rectal

tumor

T2N1M0

Complete Blood Count

IVFD RL 20 tpm

Patient discharge by permission andcontrol as outpatient

8/10/2019 MR 20-12-14

4/131

No IdentityAdmission

to E.R.Diagnosis Treatment / Planning

2 Mr. Hendri/ 20

y.o/1.13.25.87

20th

December

2014/ 16.15

Closed fracture tibia

sinistraX-ray antebrachii sinistra AP+LAT

Patient discharge by request

8/10/2019 MR 20-12-14

5/131



3 Mrs. Sarimas/

56

y.o/1.13.25.88

20th

December

2014/18.00


CT Scan Head Trauma + Facial 3D +

Bone WindowX-ray antebrachii dextra, femur dextra,

cruris dextra

IVFD RL 20 tpm

H2 Blocker

AnalgesicAntibiotic

Folley catheter

8/10/2019 MR 20-12-14

6/131



4 Ch. M. Azhar/

14 y.o/ 0-60-69-

18

20th

December

2014/ 18.40

Mild Head InjuryComplete Blood count

X-ray trauma series

IVFD RL 20 tpmH2 blocker

Analgesic

8/10/2019 MR 20-12-14

7/131



5 Mr. Kadir/ 25

y.o/ 1-13-25-91

20th

December

2014/ 18.45

Mild Head Injury + susp.

Fracture Basis cranii fossa

media

Complete Blood count

CT Scan Head

IVFD NaCl 0,9% 20 tpm

O24 lpmHead up

Antibiotic

H2 blocker

Analgesic

8/10/2019 MR 20-12-14

8/131



6 Mrs. Arbayah/

52 y.o/

1.13.25.90

20th

December

2014/ 17.15

X-ray Cruris dextra & Shoulder dextra

IVFD RL 20 tpm

Analgesic

Arm sling

8/10/2019 MR 20-12-14

9/131



7 Mr. Sabli/ 35

y.o/ 0.72.54.13

20th

December

2014/ 20.30

Hernia Inguinalis Lateralis

Sinistra InkarserataObs. vital sign

Complete blood count

IVFD RL 20 tpmAntbiotic

Analgesic

H2 blocker

Consult to Digestive surgeon

department:Pro cito herniotomy

8/10/2019 MR 20-12-14

10/131



8 Mr. Yusran/ 35

y.o/ 1.13.25.99

20th

December

2014/ 22.00

Mild Head Injury + Complete blood count

CT Scan Head

O24 lpm nasal canulFolley catheter

IVFD NaCl 2000cc/24 hours

Antibiotic

Analgesic

H2 blocker

8/10/2019 MR 20-12-14

11/131



9 Ms. Norliani/ 17

y.o/ 1.13.25.95

20th

December

2014/ 20.45


X-ray skull AP+LAT

Primary suture

8/10/2019 MR 20-12-14

12/131

8/10/2019 MR 20-12-14

13/131

1. Mr. Anang Rusdi/ 63 y.o/ 1.13.25.81

20th December 2014/ 15.00

Chief Complain : Bloody feces

History: Patient complain his bloody feces since 3 months ago.

Bloody feces come intermittent and there was much blood.Patient also feel pain when defecation. Patient work as painter.

Patient said that he lost his weight gradually and become thin

since a year ago.

8/10/2019 MR 20-12-14

14/131

8/10/2019 MR 20-12-14

15/131

General Status

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

Mouth : Wet mucous

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

Head/Neck

I : Symmetric respiratory movement, no retraction

P : Symmetric VF P : Sonor at all lung fields

A : symmetric VBS, rhonchi (-), no wheezing

Chest

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

A : Bowel sound (+)

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

P : TymphaniAbdomen

Warm extremitiesExtremities

8/10/2019 MR 20-12-14

16/131

Clinical Picture

8/10/2019 MR 20-12-14

17/131

Local Status

I : mass about 4 cm,

blood (+), pus (+)

P : consistency kenyal,

mobile

L b t i R lt (20 12 2014)

8/10/2019 MR 20-12-14

18/131

Examination Result Normal value

hemoglobin 12.8 14.00-18.00 g/dl

Leucosit 8.8 4.0-10.5 Ribu/uleritrosit 4.22 4.50-6.00 juta/ul

hematocrit 37.4 42.00-52.00 Vol%

trombocit 521 150-450 Ribu/ul

RDW-CV 14.5 11.5-14.7 %

MCV 88.8 80.0-97.0 Fl

MCH 30.3 27.0-32.0 Pg

MCHC 34.2 32.0-38.0 %

Gran% 80.4 50.0-70.0 %

Limfosit% 14.3 25.0-40.0 %

MID% 5.3 3.0-9.0 %

Laboratorium Result (20-12-2014)

8/10/2019 MR 20-12-14

19/131


Gran# 7.10 2.50-7.00 Ribu/ul

Limfosit# 1.3 1.25-4.0 Ribu/ul

MID# 0.4 Ribu/ulRandom Blood

Glucose

98

8/10/2019 MR 20-12-14

20/131

Working Diagnosis

Bloody feces due to Rectal tumor

T2N1M0

8/10/2019 MR 20-12-14

21/131

Management

Complete Blood CountIVFD RL 20 tpm

Patient discharge by permission and control

as outpatient

8/10/2019 MR 20-12-14

22/131

2. Mr. Hendri/ 20 y.o/ 1.13.25.87

20thDecember 2014/ 16.15

Chief Complain : Pain at left hand

History: 30 minutes before admission, patient had

an accident. Patient was riding motorbike and hit

other vehicle from other side. Then patient fell to

the left side and hit his left hand.

8/10/2019 MR 20-12-14

23/131

Primary Survey

ClearA

Clear, RR= 20 bpm, symmetric

respiratory movement, symmetricVBSB

BP : 110/70 mmHg Pulse rate :89 bpm, strong, reguler,

CRT < 2 sec.C

GCS E4V5M6, round and equalpupils diameter (3mm/3mm), light

reflexes (+/+), no paralysisD

8/10/2019 MR 20-12-14

24/131

A -

M -

P -

L2 hours before

admission

E On the road

8/10/2019 MR 20-12-14

25/131

Secondary Survey

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

Nose : No epistaxis

Mouth : Wet mucosa

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

Head/Neck

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

P : Sonor at all lung fields

A : Symmetric VBS, no rhonchi, no wheezing

Chest

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

A : Bowel sound (+)

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

P : Tymphani

Abdomen

Warm extremities

Extremities

8/10/2019 MR 20-12-14

26/131

Clinical Picture

8/10/2019 MR 20-12-14

27/131

8/10/2019 MR 20-12-14

28/131

X-ray antebrachii sinistra

8/10/2019 MR 20-12-14

29/131

Planning Diagnose

Closed fracture tibia sinistra

8/10/2019 MR 20-12-14

30/131

Management

X-ray antebrachii sinistra AP+LAT

IVFD RL 20 tpm

Patient discharge by request

8/10/2019 MR 20-12-14

31/131

3. Mrs. Sarimas/ 56 y.o/1.13.25.88


Chief Complain : Decreased consciousness

History: 6 hours before admission, patient had an accident.

Patient was hit by motorcycle. Patient complain that her righthand and leg pain and unable to move. Patient was treated at

Puskesmas Sembabani and got IVFD RL. Then she brought

directly to Ulin hospital for further treatment.

8/10/2019 MR 20-12-14

32/131

Primary Survey

Clear, Snoring (-), gurgling (-),A


respiratory movement, symmetricVBS, Rh (-/-) wh (-/-)B

BP : 100/60 mmHg Pulse rate : 74 bpm, reguler, strong

lifted, CRT >2 sec.C

GCS E4V4M6, round and equalpupils diameter (3mm/3m), light


8/10/2019 MR 20-12-14

33/131

A-

M IVFD RL

P -

L 1 hours beforeadmission

E Road

S d

8/10/2019 MR 20-12-14

34/131

Secondary survey

Head : multiple sutured woundEye : Anemic conj. (-/-), icteric sclera (-/-)Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)

Head/Neck

I : Symmetric respiratory movement, retraction (-),multiple vulnus escoriation (+)

P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)

Chest

I : Wound (-), distension (-)

A : Normal bowel soundP : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrantsAbdomen


8/10/2019 MR 20-12-14

35/131

Clinical Picture

8/10/2019 MR 20-12-14

36/131

Local Status

a/r cruris sinistra

L: swelling (+),

deformity (+)

F: pain (+), crepitation(+)

M: ROM limited due to

pain

8/10/2019 MR 20-12-14

37/131

Local Status

a/r antebrachii dextra

L: swelling (+),

deformity (+)



pain

8/10/2019 MR 20-12-14

38/131

Local Status

a/r head:

L: sutured wound (+),

swelling (+)

F: pain (+)

8/10/2019 MR 20-12-14

39/131

CT Scan Head Trauma + Facial 3D +

Bone Window

8/10/2019 MR 20-12-14

40/131

X-ray Antebrachii dextra AP+LAT

8/10/2019 MR 20-12-14

41/131

X-ray femur dextra AP+LAT

8/10/2019 MR 20-12-14

42/131

X-ray cruris dextra AP+LAT


8/10/2019 MR 20-12-14

43/131



Leucosit 8.9 4.0-10.5 Ribu/uleritrosit 3.45 4.50-6.00 juta/ul



RDW-CV 14.1 11.5-14.7 %

MCV 88.6 80.0-97.0 Fl

MCH 29.2 27.0-32.0 Pg

MCHC 33.1 32.0-38.0 %

Gran% 81.0 50.0-70.0 %

Limfosit% 15.3 25.0-40.0 %

MID% 3.7 3.0-9.0 %

Laboratorium Result (20 12 2014)


8/10/2019 MR 20-12-14

44/131


Gran# 7.20 2.50-7.00 Ribu/ul


MID# 0.3 Ribu/ulPT Result 12.5 9.9-13.5 Detik

INR 1.09 -

Control Normal

PT

11.4 - -

APTT Result 19.0 22.2-37.0 Detik

Control Normal

APTT

26.1 -

Random Blood

Glucose

185

8/10/2019 MR 20-12-14

45/131

Working Diagnosis

8/10/2019 MR 20-12-14

46/131

Management


CT Scan Head Trauma + Facial 3D + Bone Window

X-ray antebrachii dextra, femur dextra, cruris dextra

IVFD RL 20 tpm

H2 Blocker

Analgesic

Antibiotic

Folley catheter

8/10/2019 MR 20-12-14

47/131

4. Ch. M. Azhar/ 14 y.o/ 0-60-69-18


Chief Complain :

History: 20 minutes before admission, patient had an accident

at Kuripan. Patient admit that he hit person when across the

road. When patient try to avoid that person, he fell from his

motorcycle. His mouth got blunt trauma. Patient use helmet

when riding. History of unconscious (-), vomit (-), blood from

mouth/nose/ear (+/+/-).

8/10/2019 MR 20-12-14

48/131

Primary Survey








8/10/2019 MR 20-12-14

49/131

A -

M -

P -


E Road

Secondary survey

8/10/2019 MR 20-12-14

50/131

Secondary survey

Eye : Anemic conj. (-/-), icteric sclera (-/-)

Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)

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 (-), vulnus escoriation (-)

A : Normal bowel sound

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


8/10/2019 MR 20-12-14

51/131

Clinical Picture

8/10/2019 MR 20-12-14

52/131

X-ray Skull AP+LAT

8/10/2019 MR 20-12-14

53/131

X-ray Cervical AP+LAT

8/10/2019 MR 20-12-14

54/131

X-ray Thorax AP

8/10/2019 MR 20-12-14

55/131

X-ray Pelvis


8/10/2019 MR 20-12-14

56/131



Leucosit 19.7 4.0-10.5 Ribu/ul

eritrosit 5.91 4.50-6.00 juta/ul



RDW-CV 15.1 11.5-14.7 %MCV 69.2 80.0-97.0 Fl

MCH 22.8 27.0-32.0 Pg

MCHC 33.0 32.0-38.0 %

Gran% 84.2 50.0-70.0 %

Limfosit% 8.7 25.0-40.0 %

MID% 7.1 3.0-9.0 %

( )


8/10/2019 MR 20-12-14

57/131

Gran# 16.60 2.50-7.00 Ribu/ul


MID# 1.4 Ribu/ul

PT Result 11.3 9.9-13.5 Detik

INR 0.99 -

Control Normal

PT

11.4 - -


Control Normal

APTT

26.1 -

Random Blood

Glucose

131

8/10/2019 MR 20-12-14

58/131

Working Diagnosis

Mild Head Injury

8/10/2019 MR 20-12-14

59/131

Management


X-ray trauma series

IVFD RL 20 tpm

H2 blocker

Analgesic

8/10/2019 MR 20-12-14

60/131

5. Mr. Kadir/ 25 y.o/ 1-13-25-91


Chief Complain : Bleeding from left ear

History: One hour before admission, patient had an accident

when he was riding motorcycle. Helmet (+). In Kayutangi he

was hit by another motorcycle, he fell and his head hit the

ground. History of unconsciousness (-), history of vomiting (+),

history of bleeding from ear (+), nose (+), mouth (-). He was

brought by civilian to Ulin general hospital.

8/10/2019 MR 20-12-14

61/131

Primary Survey








8/10/2019 MR 20-12-14

62/131

A -M -

P -

L

3 hours before

admission

E On the road

Secondary survey

8/10/2019 MR 20-12-14

63/131

Secondary survey

Vulnus escorea e/r supra orbita sinistra 1 cmVulnus escorea e/r zygoma dextra 3 cmVulnus escorea e/r 10x2 cmEye : Anemic conj. (-/-), icteric sclera (-/-)Ear : otthorea (+)Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)

Head/Neck

I : Symmetric respiratory movement, retraction (-) P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)

Chest


A : Normal bowel soundP : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrants

Abdomen

Warm extremities e/r antebrachii dextra: vulnus escorea 2 x 5 cm e/r genu sinistra vulnus escorea multiple

e/r digiti 345 pedis sinistra: vulnus escorea multiple

Extremities

8/10/2019 MR 20-12-14

64/131

Clinical Picture

8/10/2019 MR 20-12-14

65/131

Local Status

a/r head

Vulnus escoriatum(+)

8/10/2019 MR 20-12-14

66/131

Local Status

a/r ear

L: blood (+)


8/10/2019 MR 20-12-14

67/131







RDW-CV 15.0 11.5-14.7 %MCV 80.0 80.0-97.0 Fl

MCH 26.9 27.0-32.0 Pg

MCHC 33.7 32.0-38.0 %

Gran% 78.5 50.0-70.0 %

Limfosit% 15.2 25.0-40.0 %

MID% 6.3 3.0-9.0 %

8/10/2019 MR 20-12-14

68/131

CT Scan Head


8/10/2019 MR 20-12-14

69/131

Gran# 8.20 2.50-7.00 Ribu/ul


MID# 0.6 Ribu/ul


INR 0.84 -

Control Normal

PT

11.4 - -


Control Normal

APTT

26.1 -

Random Blood

Glucose

130

8/10/2019 MR 20-12-14

70/131

Working Diagnosis

Mild Head Injury + susp. Fracture Basis cranii fossa media

8/10/2019 MR 20-12-14

71/131

Management

Complete Blood count

CT Scan Head

IVFD NaCl 0,9% 20 tpm

O24 lpm

Head up

Antibiotic

H2 blocker

Analgesic

8/10/2019 MR 20-12-14

72/131

6. Mrs. Arbayah/ 52 y.o/ 1.13.25.90


Chief Complain :

History:

8/10/2019 MR 20-12-14

73/131

Primary Survey


Clear, RR= 22 bpm, symmetricrespiratory movement, symmetric

VBS, Rh (-/-) wh (-/-)B





8/10/2019 MR 20-12-14

74/131

A -M

IVFD RL 20 tpm, Inj.Ketorolac 30 mg

P -

L

4 hours before

admission

E On the road

8/10/2019 MR 20-12-14

75/131

8/10/2019 MR 20-12-14

76/131

Clinical Picture

8/10/2019 MR 20-12-14

77/131

Local Status

a/r cruris dextra

L: swelling (+), open

wound (-)



pain

8/10/2019 MR 20-12-14

78/131

Local Status

a/r clavicula dextra

L: swelling (-)

F: pain (+), crepitation

(+) M: ROM limited due to

painS

8/10/2019 MR 20-12-14

79/131

X-ray cruris dextra

8/10/2019 MR 20-12-14

80/131

X-ray clavicula dextra

8/10/2019 MR 20-12-14

81/131

Working Diagnosis

Fraktur tibia fibula + clavicula dextra

8/10/2019 MR 20-12-14

82/131

Management

X-ray Cruris dextra & Shoulder dextra

IVFD RL 20 tpm

Analgesic

Arm sling

Posterior slab

8/10/2019 MR 20-12-14

83/131

After Posterior slab & Arm sling

8/10/2019 MR 20-12-14

84/131

7. Mr. Sabli/ 35 y.o/ 0.72.54.13


Chief Complain : Lumph in groin

History: 4 hours before admission to hospital, patient complain

about lumph in groin that cantget in. The lumph was appear

since 5 months ago but never stay. The lumph can get bigger

and swollen by itself. The lumph get bigger when he work sohard or lift something weight. Patient work as labour.

8/10/2019 MR 20-12-14

85/131

Vital Sign

BP : 120/80 mmHg

PR : 72 bpm

RR : 18 tpm

T : 36,7oC

General Status

8/10/2019 MR 20-12-14

86/131



Head/Neck


Chest





8/10/2019 MR 20-12-14

87/131

Clinical Picture

8/10/2019 MR 20-12-14

88/131

Local Status

a/r inguinal et scrotalis

sinistra

Mass 10 cm

Bowel sound (+)

8/10/2019 MR 20-12-14

89/131

Rectal Toucher

TSA strong

Ampulla isnt collapse

Mass (-)

NT (-)

Mukosa licin

Feces (+), blood (-)



8/10/2019 MR 20-12-14

90/131







RDW-CV 15.4 11.5-14.7 %MCV 77.1 80.0-97.0 Fl

MCH 25.1 27.0-32.0 Pg

MCHC 32.6 32.0-38.0 %

Gran% 82.2 50.0-70.0 %

Limfosit% 10.5 25.0-40.0 %

MID% 7.3 3.0-9.0 %


Gran# 17 10 2 50-7 00 Ribu/ul

8/10/2019 MR 20-12-14

91/131

Gran# 17.10 2.50 7.00 Ribu/ul


MID# 1.5 Ribu/ul


INR 1.09 -

Control Normal

PT

11.4 - -


Control Normal

APTT

26.1 -

Random Blood

Glucose

200

8/10/2019 MR 20-12-14

92/131

Working Diagnosis

Hernia Inguinalis Lateralis Sinistra Inkarserata

8/10/2019 MR 20-12-14

93/131

Management

Obs. vital sign


IVFD RL 20 tpm

Antbiotic

Analgesic

H2 blocker

Consult to Digestive surgeon department: Pro cito herniotomy

8 M Y / 32 / 1 13 2 99

8/10/2019 MR 20-12-14

94/131

8. Mr. Yusran/ 32 y.o/ 1.13.25.99


Chief Complain : Pain in face

History: 5 hours before admission patient had an accident.

Mechanism of trauma was unknown. Patient was brought by

police officer to Ratu Zalecha hospital. History of

unconsciousness (-), history of vomiting (-), history of bleedingfrom mouth/ear/nose (+/+/+). Patient then refer to Ulin hospital

for further treatment.

8/10/2019 MR 20-12-14

95/131

Primary Survey



VBS, Rh (-/-) wh (-/-)B





A -

8/10/2019 MR 20-12-14

96/131

M

IVFD NaCl 20 tpm +

tramadol, Inj.Ketorolac 30 mg, Inj.

Kalnex, Inj. Piracetam,Inj. Ranitidin, Inj.

ceftriaxone

P -


E On the road Secondary survey

8/10/2019 MR 20-12-14

97/131

Disk face (+)L: Open wound a/r supra orbita dextra 5 x 1 cm.based on bone

F: crepitation (+)Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)

Head/Neck


Chest

I : Wound (-), distension (-), vulnus escoriation (-),jejas (+)




8/10/2019 MR 20-12-14

98/131

Clinical Picture

8/10/2019 MR 20-12-14

99/131

CT Scan Head

8/10/2019 MR 20-12-14

100/131

8/10/2019 MR 20-12-14

101/131

X-ray cruris sinistra



8/10/2019 MR 20-12-14

102/131






RDW-CV 14.8 11.5-14.7 %

MCV 89.8 80.0-97.0 Fl

MCH 31.0 27.0-32.0 Pg

MCHC 34.6 32.0-38.0 %

Gran% 85.1 50.0-70.0 %Limfosit% 8.0 25.0-40.0 %

MID% 6.9 3.0-9.0 %


Gran# 18.60 2.50-7.00 Ribu/ul

8/10/2019 MR 20-12-14

103/131


MID# 1.5 Ribu/ul


INR 1.00 -

Control Normal

PT

11.4 - -


Control Normal

APTT

26.1 -

Random Blood

Glucose

154

8/10/2019 MR 20-12-14

104/131

Working Diagnosis

Mild Head Injury + fracture ??

M t

8/10/2019 MR 20-12-14

105/131

Management

Complete blood count CT Scan Head

X-ray cruris sinistra

O24 lpm nasal canul Folley catheter

IVFD NaCl 2000cc/24 hours

AntibioticAnalgesic

H2 blocker

9 Ms Norliani/ 17 y o/ 1 13 25 95

8/10/2019 MR 20-12-14

106/131

9. Ms. Norliani/ 17 y.o/ 1.13.25.95


Chief Complain :

History: Post KLLD

P i S

8/10/2019 MR 20-12-14

107/131

Primary Survey



VBS, Rh (-/-) wh (-/-)

B





8/10/2019 MR 20-12-14

108/131

A -

MIVFD RL 20 tpm, Inj.

Ketorolac 30 mg

P -

L4 hours before

admission

E On the road

Secondary survey

8/10/2019 MR 20-12-14

109/131



Head/Neck

I : Symmetric respiratory movement, retraction (-) P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)Chest





Cli i l Pi t

8/10/2019 MR 20-12-14

110/131

Clinical Picture

L l St t

8/10/2019 MR 20-12-14

111/131

Local Status

a/r parietal

X Sk ll AP+LAT

8/10/2019 MR 20-12-14

112/131

X-ray Skull AP+LAT



8/10/2019 MR 20-12-14

113/131






RDW-CV 12.7 11.5-14.7 %

MCV 84.4 80.0-97.0 Fl

MCH 27.9 27.0-32.0 Pg

MCHC 33.1 32.0-38.0 %

Gran% 80.3 50.0-70.0 %Limfosit% 12.3 25.0-40.0 %

MID% 7.4 3.0-9.0 %


Gran# 12.20 2.50-7.00 Ribu/ul

8/10/2019 MR 20-12-14

114/131


MID# 1.1 Ribu/ul


INR 0.80 -

Control Normal

PT

11.4 - -


Control Normal

APTT

26.1 -

SGOT 31 0-46 U/I

SGPT 22 0-45 U/IUrea 17 10-50 Mg/dL

Creatinine 0.6 0.7-1.4 Mg/dL

Working Diagnosis

8/10/2019 MR 20-12-14

115/131

Working Diagnosis

Mild Head Injury

Management

8/10/2019 MR 20-12-14

116/131

Management

Complete blood count X-ray skull AP+LAT

Primary suture

10 Mr Zaini/ 20 y o/ 1 13 26 06

8/10/2019 MR 20-12-14

117/131

10. Mr. Zaini/ 20 y.o/ 1.13.26.06


Chief Complain : Bleeding from nose

History: 6 hours before admission, patient had an accident.

Patient had an open wound on head and fracture of right hand.

History of unconsciousness (-), history of vomiting (-), bleedingfrom nose (+).

8/10/2019 MR 20-12-14

118/131

8/10/2019 MR 20-12-14

119/131

A -

MIVFD RL, Inj. Ketorolac30 mg, Inj. Cefotaxime,

Inj. ranitidin

P -

L6 hours before

admission

E On the road

Secondary survey

8/10/2019 MR 20-12-14

120/131



Head/Neck

I : Symmetric respiratory movement, retraction (-) P : Symmetric VF

P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)Chest



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

Abdomen


Clinical Picture

8/10/2019 MR 20-12-14

121/131

Clinical Picture

Local status

8/10/2019 MR 20-12-14

122/131

Local status

a/r frontal

Local Status

8/10/2019 MR 20-12-14

123/131

Local Status

a/r antebrachii dextra

L: swelling (+),

deformity (+)



pain

X ray Thorax AP

8/10/2019 MR 20-12-14

124/131

X-ray Thorax AP

X ray skull AP+LAT

8/10/2019 MR 20-12-14

125/131

X-ray skull AP+LAT

X-ray cruris dextra

8/10/2019 MR 20-12-14

126/131

X-ray cruris dextra

CT Scan Head

8/10/2019 MR 20-12-14

127/131

CT Scan Head

8/10/2019 MR 20-12-14

128/131

Working Diagnosis

8/10/2019 MR 20-12-14

129/131

Working Diagnosis

Mild Head Injury + Fracture radius ulna dextra

Management

8/10/2019 MR 20-12-14

130/131

Management

CT Scan Head Folley catheter

IVFD RL 20 tpm

Antibiotic

Analgesic

H2 blocker

8/10/2019 MR 20-12-14

131/131

THANK YOU

MR 20-12-14

Documents

Transcript of MR 20-12-14