Professional Documents
Culture Documents
jan
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
Urology surgery
:3
Neurosurgery
:1
Pediatric surgery
Orthopedic
Total
:1
:7
Patients List
N
o
Identity
Admissio
n to E.R.
Diagnosis
Management
Mr. Fajar,
26 yo/
Decemb
er 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
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
N
o
Identity
2. Mr.
Rizkian
12 yo/
3.
Admission
to E.R.
Diagnosis
Decembe
r 22nd
2014 at
18.05
Lacerated
wound at
right
antebrachii
region
Management
Debridement
ATS
Primary Suture
Oral Med:
Antibiotic
Analgetic
H2 Blocker
Consult to digestive
surgery:
Obsv. Vital sign
Co. Urology
Patients List
N
o
Identity
Admissio
n to E.R.
Diagnosis
4 Mr.
. Rusbani
50 yo/
Decemb
er 22nd
2014 at
21.00
Fistula
Vesico
Cutaneus
post
open
prostatecto
my
+
Anemia
+
Trombositop
eni
+
hypoalbune
mia+ 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
N
o
Identity
Admissio
n to E.R.
5 Mr.
. Samsul
Bahri
45 yo/
Decemb
er 22nd
2014 at
22.30
6 Mr.
. Mulyana
55 yo/
Diagnosis
Mild head
injury GCS
15 +
lacerated
wound at
right
periorbita
region +
lacerated
wound at
right knee
Decemb region
er 22nd
2014 at
22.55
Post
Open
Cystotomy
d.t
Susp
Stricture
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
N
o
Identity
7 Mr.
. Samuel
Salodon
g 31 yo/
Admissio
n to E.R.
Diagnosis
Decemb
er 23rd
2014 at
02.15
Closed
fracture of
the right
tibia distal
third (intra
artikular)
comminutive
displaced
Management
Consult to Ortopaedy
Posterior slab
Analgetic
H2 Blocker
Pro ORIF elective
Primary Survey
A
B
Secondary Survey
Head/Nec
k
Chest
Abdomen
Extremitie
s
(-)
(-)
On the road
Localized Status
Localized Status
Localized Status
Localized Status
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 (-)
Femur X-ray
December, 22nd 2014
LABORATORY FINDING
13,5
Result
HEMATOLOGY
Parameter
Normal Value
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
GDP
135
SGOT/ SGPT
133/49
0,7-1,4
mg/dL
<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
SATUAN
22,2-37 dtk
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. Rizkian
12 yo/ December
Suri/ 50 Yo/1-11-55-77
22nd 2014 at 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
Secondary Survey
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. Arkasi
61
yo/ December 22nd
Suri/ 50
Yo/1-11-55-77
2014 at 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
38
Clinical Picture
Mass at scrotal
region
10cm in diameter
Solid consistencies
Reguler edge
Surgical wound +
Fibrosis at OUE
LABORATORY FINDING
13,5
Result
HEMATOLOGY
Parameter
Normal Value
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
GDS
272
SGOT/ SGPT
43/48
0,7-1,4
mg/dL
<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
SATUAN
22,2-37 dtk
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
Physical Examination
Compos Mentis
BP: 130/90mmhg
P: 108 tpm
RR: 24 tpm
T: 36, C
54
Clinical picture
a/r
LABORATORY FINDING
13,5
Result
HEMATOLOGY
Parameter
Normal Value
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
GDS
161
SGOT/ SGPT
28/19
0,7-1,4
mg/dL
<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.Suri/
Samsul
Bahri 45 yo/
50 Yo/1-11-55-77
December 22nd 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
Secondary Survey
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
Physical Examination
Compos Mentis
BP: 130/90mmhg
P: 10 tpm
RR: 24 tpm
T: 36, C
78
LABORATORY FINDING
13,5
Result
HEMATOLOGY
Parameter
Normal Value
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
Creatinin
GDS
134
SGOT/ SGPT
17/17
Albumin
4.49
PT
4 minute
APTT
2 minute 10 second
10-50 g/dL
0,7-1,4
mg/dL
<200
mg/dL
0-45 U/I
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
SATUAN
22,2-37 dtk
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
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. Samuel
Salodong 31 yo/
Suri/ 50 Yo/1-11-55-77
December 23rd 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
Secondary Survey
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