Resident in charge:Alma wijayaTeam members :Irzal, Fariz, Adit, Ani, Erna, AidaChief in charge :Dita Dwi RamadhaniEMERGENCY ROOM REPORT NOVEMBER 20th-21st 2014

NoIdentityTime of admissionDiagnosisTreatment / Planning1Mr. Lider/65 Y.o/1-12-89-76November 20th, 2014/16.40 Intraabdominal mass suspect HCC KPS 20 Uremic syndrome suspect hepatorenal syndrome Severe sepsisObservation of vital signsComplete blood count

Consult to digestive surgery division: hospitalized Fluid resucitationAntibiotic H2 blocker Analgetic Observation of urine outputJoin care with interna departement

NoIdentityTime of admissionDiagnosisTreatment / Planning2Baby Akhmad/3 days old/1-12-89-81/November 20th, 2014/18.00 Atresia of esophagusHead up 300Complete blood countContinous suction of saliva on mouth

Consult to Pediatric surgery division: hospitalized

NoIdentityTime of admissionDiagnosisTreatment / Planning3Mr. Indra/18 Y.o/1-12-89-79November 20th,2014/18.00 Mild head injurySuspect skull base fracture anterior fosaa Fracture of right zygomaxilla Fracture of right rima orbitaConsult to neurosurgery division:Observation of vital sigIVFD NSConservative treatmentAntibioticH2 blockerAnalgeticHospitalized

Consult to Plastic surgery division: Pro elective ORIF Oral hygene

NoIdentityTime of admissionDiagnosisTreatment / Planning4Mr. Abidin/26 Y.o/1-12-89-86November 20th, 2014/20.30 Fracture of right orbital rim Vulnus laceratum on lateral edge of right eye Head up 300Routine blood countWound toiletAntibioticAnalgetic

Discharge by request

NoIdentityTime of admissionDiagnosisTreatment / Planning5Miss. Elis/23 Y.o/1-12-89-90November 20th, 2014/23.15 Moderate head injury with E2V5M2 (9) SDH and ICH 5cc on left temporal region Suspect fracture of cranial base right medial fossaHead up 300Complete blood countIVFD NSOxygenationHead CT-Scan

Consult to Neurosurgery division: hospitalized antibiotic H2 blocker Analgetic

Chief complaint : abdominal mass Mr. Lider/65 Y.o/1-12-89-76/November 20th, 2014/16.40 Since three months before admission, the patient complained of mass appeared on his right upper abdomen which got bigger by times. The complaint was started by intermittent paint since 1 year prior to admission. History of nausea and vomitting were reported also icteric skin. He lost his weight as well as appatite. Hes been hospitalized at Dorris Sylvanus hospital then referred to Ulin General Hospital.

Spincter ani tone (+) Smooth mucosa membrane No collapse ampulla Tenderness (-) Handscone : feces (+), blood(+) mucous (-)

A/r abdomenI : Distention (-) caput medusae - Mass (+) sized about 15 cm in diameter,fixated.A : Decrease bowel soundP : TympaniP : Tenderness (-) rebound tenderness (-) defans muscular (-)

Description :Enlarged hepar size, rough parenchyma, heterogenic hyperechoic lession apperance, rough and lobulated

Conclusion :Hepatoma dd HCC

Hb : 11,5 gr/dlWBC : 23,1 thousands/ulErithrocyte : 3,78 millions/ulHematocryte : 34,8 vol%Trombochyte : 183 thousands/ulRBG : 105 mg//dlSGOT/SGPT : 80/38 U/lAlbumin : 3,3 mg/dlUr/Cr : 162/1,8 mg/dlPT/APTT : 12,3/24,0 mmol/lHBsAg : negativeBilirubin T/D/I : 3,76/2,97/0,79mg/dl

Intraabdominal mass suspect HCC KPS 20 Uremic syndrome suspect hepatorenal syndrome Severe sepsis

Consult to digestive surgery division: hospitalized Fluid resucitationAntibiotic H2 blocker Analgetic Observation of urine outputJoint care with interna departement

Observation of vital signsComplete blood count

Baby Akhmad/3 days old/1-12-89-81/November 20th, 2014/18.00 Chief complaint : Choking and vomitting everytime breastfeededThe baby was born three days prior to admission. Everytime he was breatfeeded, he would vomit and choked. This complaint was also accompanied by foamy drool. His birth was assissted by midwive spontaneously. He had history of severe asphyxia. He was hospitalized in Kandangan general hospital and underwent several x-ray examination before finally referred to Ulin General Hospital for further treatment. He was second child family without miscarriage history in his family. According to the mother she started her ANC programme on the fifth month of pregnancy.

Hb : 14,0 gr/dlWBC : 10,0 thousands/ulErithrocyte : 4,06 millions/ulHematocryte : 40,8 vol%Trombochyte : 336 thousands/ulRBG : 116 mg//dlSGOT/SGPT : 35/25 U/lAlbumin : 4,3 g/dlUr/Cr : 16/0,3 mg/dlPT/APTT : 9,9/44,5 secondsNa/K/Cl : 132,8/4,2/98,3 mmol/l

Atresia of esophagus

Consult to Pediatric surgery division: hospitalized

Head up 300Complete blood countContinous suction of foam on mouth

Mr. Indra/18 Y.o/1-12-89-79/November 20th, 2014/18.00 Chief complaint : HeadacheOne hour prior to admission the patient was riding his motorcycle around Gambut region. He was in volved in a crush with another motorcycle from opposite direction. He fell down and his head hit the road. He fainted andhistory of bleeding from nose and mouth was reporter. He was immediately brought to nearest Public Health Center then referred to Ulin for further treatment.

A/r head : Brill hematoma (+/+) Battle sign (-/-) Rinorrhae (+) Halo test (+)A/r Maxillofacial : Malocclution (-) edema (-) deformitas (+)Mandible stability : StabilFloating maxilla (-)

A/r manus dextra:L : vulnus laceratum (+) at digiti iv dextraF : tenderness (+) crepitation (-)M : limited due to pain

Hb : 13,7 gr/dlWBC : 8,5 thousands/ulErithrocyte : 4,58 millions/ulHematocryte : 38,8 vol%Trombochyte : 202 thousands/ulRBG : 106 mg//dlSGOT/SGPT : 34/22 U/lUr/Cr : 36/0,9 mg/dlPT/APTT : 9,2/22,3 seconds

Mild head injurySuspect skull base fracture anterior fosaa Fracture of right zygomaxilla Fracture of right rima orbita

Consult to Plastic surgery division: Pro elective ORIF Oral hygene

Consult to neurosurgery division:Observation of vital sigIVFD NSConservative treatmentAntibioticH2 blockerAnalgeticHospitalized

Mr. Abidin/26 Y.o/1-12-89-86/November 20th, 2014/20.30 Chief complaint : Swollen faceFive minutes before admission, the patient was involved in a accident when he was riding motorcycle with his friend as passanger. They were aboutmaking a U-turn when suddenly a car hit their motorcycle from right side. He was thrown away and his right face hit the road. He didint use a helmet. No history of bleeding from ears, nose, or month. He also didnt either fainting or vomitting. He was immediately sent to Ulin general hospital

A/r right temporal :L : Swollen upper lid (+) wound (+)F : crepitation (+) tenderness (+)

Hb : 14,7 gr/dlWBC : 13,0 thousands/ulErithrocyte : 4,58 millions/ulHematocryte : 43,1 vol%Trombochyte : 183 thousands/ul

Fracture of right orbital rim Vulnus laceratum on lateral edge of right eye

Head up 300Routine blood countWound toiletAntibioticAnalgetic

Discharge by request

Miss. Elis/23 Y.o/1-12-89-90/November 20th, 2014/23.15 Chief complaint : Decrease of conciousnessNine hours prior to admission, the patient was riding her motorcycle when a car stumbled over her. She fell down and hit the road. She fainted and history of bleeding earswas reported. She was sent to Tanah Bumbu general hospital. She was referred to Ulin General Hospital for further treatment.

A/r Head:Racoon eyes (-/-)Otorrhae (+/-)Rinorrhae (-/-)Battle sign (+/-)

A/r Right arm:L : swelling (+) deformity (-)F : Tenderness (+)M: Limited

Hb : 9,8 gr/dlWBC : 13,4 thousands/ulErithrocyte : 3,07 millions/ulHematocryte : 29,6 vol%Trombochyte : 174 thousands/ulRBG : 153 mg//dlSGOT/SGPT : 43/20 U/lUr/Cr : 14/0,7 mg/dlNa/K/Cl : 138,1/3,7/102,1 mmol/l

Moderate head injury with E2V5M2 (9) SDH and ICH 5cc on left temporal region Suspect fracture of skull base right medial fossa

Consult to Neurosurgery division: hospitalized antibiotic H2 blocker Analgetic

Head up 300Complete blood countIVFD NSOxygenationHead CT-Scan

THANK YOU!FOR YOUR ATTENTIONSurgery departement

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