Emergency Case Report

June 19st-20nd, 2015

Resident on duty: dr. Fitriadi Sejati
Chief co-ass: Rizki Agmalia Sorayya
Team:
Indah Dwitari, M. Hendy Arizal, M. Nasrullah, Devita
Wijayanti, Khairunnisa Saputri, Indah Sarweny

Minor Surgery

Digestive Surgery

Thorax Cardiovascular Surgery :

Plastic Surgery

Urology Surgery

Neuro Surgery

Pediatric Surgery

Oncology Surgery

Orthopaedy
Total

:
:

Patient List
No
1.

Identity
Ny. Rusmina /60
yo/ 1-15-49-74

Admission
to ER
June 19th,
2015
at 17.10
WITA

Diagnose
Aneurisma Aorta

Treatment
VS Obs
Complete blood
count
USG abdomen
Thorax photo
H2 blocker
Vit c
IVFD RL
Consulted to
digestive surgeon
- CT-scan
abdomen

Patient List
No
2.

Identity
Ny. rosinah/ 55
y.o/

Admission
to ER
June 19th,
2015
at 17.40
WITA

Diagnose
lleus obstructive
total

Treatment
VS Obs
Complete blood
count
USG abdomen
Thorax photo
H2 blocker
Vit c
IVFD RL
Consulted to
digestive
surgeon:
- Laparotomy
exploration

Patient List
No
3.

Identity
An. Rifki/ 2 y.o/

Admission
to ER
June 20th,
2015
at 02.00
WITA

Diagnose

Treatment
VS Obs
Complete blood
count
USG abdomen
Thorax photo
H2 blocker
IVFD RL
Consulted to
digestive
surgeon:

1. Ny. Rusmina /60 th/1-15-49-74

Chief Complain:
Nyeri perut
Anamnesis:
2 hari SMRS, pasien mengeluh nyeri perut di
bagian kiri yang muncul hilang timbul. Ada riwayat
mual (+) dan muntah (+) sejak kemarin. Pasien
juga mengeluh kehilangan nafsu makan. Tidak ada
riwayat penyakit keluarga yang sama seperti ini.
Karena keluhannya, pasien pergi ke RS Sampit dan
dirujuk ke RS Ulin untuk penanganan lebih lanjut.

Working Diagnosis

Abdominal mass susp. aneurisma aorta

abdominalis

Vital sign
BP : 100/70 mmhg
PR : 84 x/min
RR : 24 x/min
T

: 36,9 c

Primary Survey

Head

General Status

Clinical Picture

Local Pictures

X-ray Thorax

Abdomen 2 position

USG abdomen

USG abdomen

USG abdomen

Complete Blood Count Result

June 19st, 2015 at 17.39 WITA
Items

Result

Normal Value

Unit

Hemoglobine

4.9

14.00 - 18.00

g/dl

Leukocyte

15.1

4.0 10.5

thousand/ul

Eritrocyte

1.89

4.00 5.50

million/ul

Hematocrit

15.2

32.00 44.00

Vol%

Thrombocyte

162

150 450

Ribu/ul

RDW-CV

15.6

11.5 14.7

MCV

80.7

80.0 97.0

Fl

MCH

25.9

27.0 32.0

Pg

MCHC

32.2

32.0 38.0

Complete Blood Count Result

June 19st, 2015 at 17.39 WITA
Items

Result

Normal Value

Unit

Gran%

85.3

50.0-70.0

Lymphosite%

8.7

25.0-40.0

MID%

6.0

4.00-11.00

million/ul

12.90

2.50-7.00

Billion/ul

Limfosit #

1.3

1.25-4.0

Billion/ul

MID#

0.9

Gran#

Billion/ul

Complete Blood Count Result

June 19st, 2015 at 17.39 WITA
Items

Result

Normal Value

Unit

GDS

227

<200

Mg/dL

PT

1.09

9,9-13,5

Second

APTT

22.3

22,2-37,0

Second

INR

1.09

SGOT

42

0-46

U/l

SGPT

30

0-45

U/l

Ureum

105

10-50

mg/dL

Creatinin

2.1

0,7-1,4

mg/dL

Management

VS Observation
Complete blood count
Thorax photo
USG abdominal
EKG
IVFD RL
H2 blocker
Vit c

Consulted digestive surgery :

Pro CT-scan abdomen
R

2. Ny. Rosinah /55 th

Chief Complain:
Perut kembung
Anamnesis:
3 bulan SMRS, pasien mengeluh perut kembung dan
tidak bisa BAB. Pasien juga mengeluh ada nyeri
perut. Ada riwayat pijat perut tradisional. Pasien
dibawa ke RS Barabai untuk 16 hari. Setelah itu,
pasien kembali ke rumah. Setelah 20 hari kemudian,
pasien mengalami pijatan dan konstipasi. Pasien
dibawa ke RS Damanhuri lagi. Lalu pasien dirujuk ke
RS Ulin untuk penanganan selanutnya.

Working Diagnosis

Illeus obstructive total

Vital sign
BP 170/100 mmhg
PR 112x/min
RR 22x/min
T 36,9 c

Primary Survey

Head

General Status

Clinical Picture

Local Pictures

Local picture

X-ray Thorax

Colon in loop

Colon in loop

Colon in loop

Abdomen 3 position

Abdomen 3 position

EKG

Complete Blood Count Result

June 19st, 2015 at 23.16 WITA
Items

Result

Normal Value

Unit

Hemoglobine

14.6

14.00 - 18.00

g/dl

Leukocyte

9.2

4.0 10.5

thousand/ul

Eritrocyte

4.77

4.00 5.50

million/ul

Hematocrit

43.5

32.00 44.00

Vol%

Thrombocyte

437

150 450

Ribu/ul

RDW-CV

13.0

11.5 14.7

MCV

91.3

80.0 97.0

Fl

MCH

30.6

27.0 32.0

Pg

MCHC

33.5

32.0 38.0

Complete Blood Count Result

June 19st, 2015 at 23.16 WITA
Items

Result

Normal Value

Unit

Gran%

75.5

50.0-70.0

Lymphosite%

14.4

25.0-40.0

MID%

10.1

4.00-11.00

million/ul

7.00

2.50-7.00

Billion/ul

Limfosit #

1.3

1.25-4.0

Billion/ul

MID#

0.9

Gran#

Billion/ul

Complete Blood Count Result

June 19st, 2015 at 23.16 WITA
Items

Result

Normal Value

Unit

GDS

124

<200

Mg/dL

PT

11.7

9,9-13,5

Second

APTT

22.6

22,2-37,0

Second

INR

1.03

SGOT

18

0-46

U/l

SGPT

0-45

U/l

Bilirubin total

0.52

0.20-1.20

mg/dL

Bilirubin direk

0.39

0.00-0.40

mg/dL

Bilirubin indirek

0.13

0.20-0.60

mg/dL

SGOT

18

0-46

U/l

SGPT

0-46

U/l

Ureum

32

10-50

mg/dL

Management

VS Observation
Complete blood count
IVFD RL
H2 blocker
Antibiotic
Rectal tube
NGT
Urine catheter

Consulted to digestive surgeon :

Pro laparotomy exploration cito
R

3. An. Rifki /2 yo/1-15-49-95

June 20th, 2015
Chief Complain:
Ascites
Anamnesis:
3 days before admission, the abdoment of patient
became larger than before. Theres history of VP-Shunt at
December 2014 in general ulin hospital with diagnosed
hydrocephalus. Theres no history of decrease
conciousness. Theres no convultion (-). Theres no
history of vommitus and nausea. Because of his
complain, patient brought to RS Tanah Bumbu. Then,
patient referred to General Ulin hospital for further
treatment.

Vital sign
BP : / mmhg
PR : 114x/min
RR : 34x/min
T

: 36,9 c

Primary Survey

Head

General Status

Clinic Pictures

Local Pictures

X-Ray Thorax

Result :
Ascites Permagna

Complete Blood Count Result

June 20th, 2015
Items

Normal Value

Unit

14.00 - 18.00

g/dl

Leukocyte

4.0 10.5

thousand/ul

Eritrocyte

4.00 5.50

million/ul

32.00 44.00

Vol%

Thrombocyte

150 450

Ribu/ul

RDW-CV

11.5 14.7

MCV

80.0 97.0

Fl

MCH

27.0 32.0

Pg

MCHC

32.0 38.0

Hemoglobine

Hematocrit

Result

Complete Blood Count Result

June 20th, 2015
Items

Normal Value

Unit

Gran%

50.0-70.0

Lymphosite%

25.0-40.0

MID%

4.00-11.00

million/ul

2.50-7.00

Billion/ul

1.25-4.0

Billion/ul

Gran#
Limfosit #
MID#

Result

Billion/ul

Complete Blood Count Result

June 20th, 2015
Items

Normal Value

Unit

<200

Mg/dL

9,9-13,5

Second

22,2-37,0

Second

SGOT

0-46

U/l

SGPT

0-45

U/l

10-50

mg/dL

0,7-1,4

mg/dL

GDS
PT
APTT

Result

INR

Ureum
Creatinin

Working Diagnosis

Ascites Post VP shunt

Management

VS Observation
Complete blood count
IVFD D5% 1/2NS 16 gtt/m
H2 blocker
analgetic

Consulted with neurosurgery :

4. Tn. Melki/27 yo/1-15-49-96

June 20th, 2015 at 02.10 WITA
Chief Complain:
Decreasing of Consciousness
Anamnesis:
5 hours before admission, the patient was on traffic
accident. He was ride a motorcycle. then he fell down
himself from his motorcycle. He didnt wear helmet.
History of fainted (+), history of bleeding from ear (-),
nose (-), and mouth (-). History of vomit (+) 3 times.
After the accident, patient was brought to PKM
Perawatan Satui Tanah Bumbu and referred to Ulin
General Hospital for further treatment.

Primary Survey

Clear, snoring (-), gurgling (-), C-spine

control (-)

Clear, RR= 24 bpm, symmetric

respiratory movement, ronkhy (-)
wheezing (-)

Pulse rate : 120 bpm, reguler, strong

lifted

GCS E2V2M4 (8), Round and symmetric

pupils diameter (2mm/2m), Light
reflexes (+/+)

Head

General Status

Clinical Picture

Local pictures

X-ray Thorax Photo

Head CT-Scan

Complete Blood Count Result

June 20st, 2015
Items

Normal Value

Unit

14.00 - 18.00

g/dl

Leukocyte

4.0 10.5

thousand/ul

Eritrocyte

4.00 5.50

million/ul

32.00 44.00

Vol%

Thrombocyte

150 450

Ribu/ul

RDW-CV

11.5 14.7

MCV

80.0 97.0

Fl

MCH

27.0 32.0

Pg

MCHC

32.0 38.0

Hemoglobine

Hematocrit

Result

Complete Blood Count Result

June 20st, 2015
Items

Normal Value

Unit

Gran%

50.0-70.0

Lymphosite%

25.0-40.0

MID%

4.00-11.00

million/ul

2.50-7.00

Billion/ul

1.25-4.0

Billion/ul

Gran#
Limfosit #
MID#

Result

Billion/ul

Complete Blood Count Result

June 20st, 2015
Items

Normal Value

Unit

9,9-13,5

Second

22,2-37,0

Second

SGOT

0-46

U/l

SGPT

0-45

U/l

10-50

mg/dL

Creatinin

0,7-1,4

mg/dL

Natrium

135-146

Mmol/l

Kalium

3,4-5,4

Mmol/l

Chlorida

95-100

Mmol/l

PT
APTT

Result

INR

Ureum

Working Diagnosis

Mild Head Injury

Management

VS Observation
IVFD NS
O2
H2 blocker
Analgetic
X-ray photos
Head CT Scan
Complete Blood Count