Emergency Report

October 15th 16th 2016

Co-ass on duty:
Pras
Adiba, Sari

General Surgery

Digestive Surgery

Thorax Cardiovascular Surgery :

Plastic Surgery

Urology Surgery

Neuro Surgery

Pediatric Surgery

Total

:
:

1
:

Oncology Surgery
Orthopaedy

Patient List
No

Identity

1. Mr. Hudori/ 50
y.o/
1.22.84.44

Admission
to ER
October,
15th 2016
09.00 pm

Diagnose

Treatment

Right hernia IVFD RL

scrotal
Antibiotic
Reponible
Analgetic
H2 blocker
Trendelenber
g
position
DC, NGT
Co to
Digestive
Observation
hospitalized
Herniotomy
elective
Patient
Discharge by
request

Patient List
No
2.

Identity
Ch. Ade Aditya/14
yo/ 1.22.84.58

Admission to
ER
October, 15th
2016
22.00 pm

Diagnose

Treatment

Closed Fracture
lateral
epycondyle right
humerus
undisplaced
+
Closed fracture
right olecranon
complete
undisplaced
+
Closed Greenstick
Fracture right
radius

Analgetic
X-ray right wrist
Co Orthopedy
Immobilisation
Circular cast
above elbow
flexi 90 degress
Arm Sling
Patient
discharge by
permission

Patient List
No

Identity

3. Mr.Abidin / 47
y.o/
1.22.84.68

Admission
to ER
October,
16th 2016
03.00 am

Diagnose
Mild Head
Injury GCS
15
+
ICH ar left &
Right
Frontotempor
al

Treatment
IVFD NS
Analgetic
H2 blocker
Antibiotik
Consult to
neurosurgery
Hospitalize

1. Mr. Hudori/ 50 y.o/ 1.22.84.44

Chief Complain :
Lump at right scrotal region
Current History :
Since 10 years before admission, patient complained about lump at
his right scrotal region that couldnt be reduced by himself and
followed by pain. History of lump apperence was since 2 month ago
with initially size as big as chicken egg. Lump appeared when
patient did heavy activity, and reduced when he got rest. He is a
farmer and he is usually lifting heavy stuffs. History of nausea (+)
and vomiting (+) 2 day before admission (when examined in the ER,
complain was (-), history of difficult to defecate (-), fever (-). History
of lifting heavy stuff (+), hystory of persistent cough(-). There is no
complain about urinating. Because of his complain he was brought
to Batu licin Hospital and then reffered to Ulin General hospital.

Vital sign

BP : 110 / 70 mmhg
HR : 71 Bpm
RR : 20 tpm
T : 36,7 0C

Head

Physical
examination

Clinical picture

Localist Status
Local Status :
Abdominal region :
flat, soft, bowel sound
(+) normal,tenderness
(-), muscular rigidity
(-)
Right groin and scrotal
region: mass 7x5x3
cm in size, bowel
sound (+), tenderness
(-), hyperemic (+)
DRE : normal sphyncter
tone, smooth mucosa,
rectal vault wasnt
collapse, tenderness
(-), mass (-)
Gloves : feces (+),
blood (-)

Working Diagnosis
Right hernia scrotal Reponible

Management
IVFD RL
Antibiotic
Analgetic
H2 blocker
Trendelenberg position
DC, NGT
Co to Digestive Surgery
Observation, hospitalized, Herniotomy elective
Patient Discharge by request

2. Ch. Ade
Aditya/46yo/1.22.84.58
Chief Complain :
Right Wrist Pain
History of Current Disease:
Since 30 minutes before admission, patient
got accident. He was riding motorcycle, then
he got hit by another motor cycle from left
side with medium acceleration. He fall to
ground and his right arm hit the ground as
well. He brought to ULIN Hospital by
emergency team. After arrived at ULIN
Hospital, He reliazed that his right cannot be
move due to pain. Helm (+), History of
unconsciousness (-), history of vomiting.
history of bleeding from ear nose and mouth

Primary survey :
A : Clear without c-spine control
B : RR 20 x/m, symmetrical shape and movement, VBS equal
C : HR :78 x/m; BP: 110/70 mmHg
D : GCS 15: E4V5M6, pupil round equal 3mm, light reflex +/+,
Lateralization (-/-) , BH (-/-), BS (-/-), BR (-/-), BO (-/-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal 2 hours before
accident
E = Environtment on the Street

Physical examination
Head

General Status

Clinical picture

Clinical Picture
At Right Wrist
L:
swelling(+),deformity
(+), wound(-)
F : Tenderness(+),
crepitation(-)
M: ROM limited d.u Pain

Wrist X-Ray

Working Diagnosis
Closed Fracture lateral epycondyle
right humerus undisplaced
+
Closed fracture right olecranon
complete undisplaced
+
Closed Greenstick Fracture right
radius

Management
Analgetic
X-ray right wrist
Co Orthopedy
Immobilisation Circular cast above
elbow flexi 90 degress
Arm Sling
Patient Discharge by Permission

3. Mr. Abidin/47 y.o./ 1.22.84.68

Chief Complain:
Headache
History of Current Disease:
Since 6 hours before admission, patient got
accident when he ride a motorcycle with medium
speed. He got hit by another mother cycle with
medium speed from right side, then he fall from
motor cycle to left side, with his head hit the road.
Helm (-), history of seizure (-), history of
unconsciousness (-), history of vomiting (+) 6 times
non projectile, Bleeding from ear (-) nose (-) mouth
(-), breathless (-). Because of his complaint patient
brought to Datu Sanggul hospital and then referred
to Ulin general hospital for further treatment.

Primary survey :
A : Clear without C Spine conttrol
B : RR 19x/m, symmetrical shape, symmetrical breathing
sound, Rh (-/-), Wh (-/-)
C : BP: 120/70 HR : 71x/m;
D : GCS 15 E4V5M6, pupil round equal 3 mm, light reflex +/+,
lateralization (-) , BH(-/-) BS(-) BO(-/-) BR (-)

Secondary survey
A = Allergy (-)
M = Medication (-)
P = Past illness (-)
L = Last meal an hour before accident
E = Environtment on the street

Physical
examination
Head

Clinical picture

Localist status
Ar. Head and
facialis :
L : swelling (-),
deformity (-),
excoriated at right
Peri Orbita (+)
F: Tenderness (+),
Crepitation (-).

Thorax X-Ray

Head CT
Scan

Head CT
Scan

Laboratory
Examination

Result

Normal value

Hemoglobin

12.0

11.00-16.00

g/dl

Leukocyte

10.8

4.0-10.5

10 /ul

Erythrocyte

4.36

4.50-6.00

10/ul

Hematocrite

37

42.00-52.00

Vol%

Platelets

178

150-450

10 /ul

RBG

172

90-200

mg/dL

AST

52

0-46

U/I

ALT

35

0-45

U/I

Urea

26

10-50

Mg/dL

Creatinin

3.7

0.6-1.2

Mg/dL

PT/APTT

10.4/25.1

second

Working Diagnosis
Mild Head Injury GCS 15
+
ICH at left & Right Frontotemporal

Management
IVFD NS
Analgetic
H2 blocker
Antibiotik
Consult to neurosurgery
Hospitalize