LapJag 8 Dan 9 Feb 2014

8/12/2019 LapJag 8 Dan 9 Feb 2014

http://slidepdf.com/reader/full/lapjag-8-dan-9-feb-2014 1/68

Emergency

Report

February 8

th

-

9

th

,

20

14

Chief on duty: Okta

Resident on duty:Dr. Alexander

Team:

Rajihah, Dila, Bayu, Farid, Joyce, Yasmin, Desy

8/12/2019 LapJag 8 Dan 9 Feb 2014


Minor surgery : -

Oncology surgery : -

Digestive surgery : 3

Thorax cardiovascular surgery : -

Plastic surgery : 1

Urology surgery : -

Neurosurgery :

Pediatric surgery : -

Orthopedic : 2

Total : 6

PATIENT LIST

8/12/2019 LapJag 8 Dan 9 Feb 2014


Patients ListNo Identity Admission to

E.R.

Diagnosis Management

1. Girl Silma

Lathifah/15y.o

February

8nd

, 2014 at 14.35

Constipation d.t

scibala with

hemorrhoid Gr.I

Laxative

Analgetic

H2 Blocker

Hemorrhoid drug

Discharge by permission

2 Boy Alex/

14 yo

February

8nd, 2014

at 18.00

Soft tissue

Swelling at right

cubiti

Analgetic IV

Rontgent Thorax and Cubiti

Co. Orthopedic

Oral Analgetic


3 Child Ida

Ariani/ 16yo

February

8nd

, 2014 at 18.00

Closed Fracture at

left ulna distal

third transvere

displace + close

fracture at left

tibial spine Meyer

Mc.Kiever II +

multiple

excoriation

IV Line

Analgetic

Antibiotic

H2 Blocker

Rontgen Thorac, pelvic , femur and

knee

Co. Orthopedic:

Posterior SlabORIF

8/12/2019 LapJag 8 Dan 9 Feb 2014


No Identity Admission to

E.R.

Diagnosis Management

4 Mrs.

Herawati/

31 yo

February

8th 2014,

at 18.20

Susp.Acute

AppendicitisIV Line

H2 blocker

Laboratory check

Co. Digestive

Appendectomy emergency

5 Baby Nilna

Muna/ 10months

February

8th

2014,at 19.10

Burn Injury at right

wrist, left tight, left

leg and left foot

Gr.IIA 3,5%

IV Line

AnalgeticWound toilet

6 Mr.

Fahruzzaini/

54 yo

February

9th 2014

at 06.30

Diffuse

peritonitis d.t

susp. Gastricperforation +

CKD gr. V

IV Line

Antibiotic

Analgetic

Laboratory check

Co. Digestive

Diuretic

Emergency Hemodialysis

Hospitalized in ICU posthemodialysis

8/12/2019 LapJag 8 Dan 9 Feb 2014


1. Girl Salma Lathifah/ 15 yo/ February 8th

2014 at 14.35

Chief complain: abdominal pain

History :

± last 2 days, patient complaint abdominal pain at whole

abdomen. The pain was intermitent. Patient also complaintconstipation. The stool was hard and often with blood at theend of defecation. Lump from anus (-)

8/12/2019 LapJag 8 Dan 9 Feb 2014


General Status

Awareness: alert

GCS15 : E4V5M6

Vital sign

• BP : 100/70 mmHg

• HR : 72 t/m

•

RR : 20 t/m• T : 36,7 oC

8/12/2019 LapJag 8 Dan 9 Feb 2014


Physical Examination

•

Eyes : No anemic conjunctivae, icteric sclerae (-),•Nose : No epistaxis

•Mouth : wet mucosa

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

Head/Neck

• I : symmetric respiratory movement,

•P : symmetric VF (+/+)•P : sonor at all lung

•A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)

Chest

• I : flat, distention (-)

•A : normal Bowel sound

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

rebound tenderness (-)•P : Tympani

Abdomen

•Warm,, no parese, no edemExtremities

8/12/2019 LapJag 8 Dan 9 Feb 2014


Physical Examination• Local status :

Flat, supple, tenderness(-),

Rebound tenderness (-),

normal bowel sound

8/12/2019 LapJag 8 Dan 9 Feb 2014


8/12/2019 LapJag 8 Dan 9 Feb 2014


Laboratory Findings

• Hemoglobin : 11,1

• WBC : 7,5

•

RBC : 4,58• Hematocrit: 35,1

• PLT: 375

8/12/2019 LapJag 8 Dan 9 Feb 2014


Laboratory Findings

Urinalize

• Color Cloudy Yellow

• BJ : 1.010

• pH: 6,5

• Keton: -

• Occult Blood: -

• Urobilinogen: 0,2

Sediment

•Leucosit 3-5

•Erytrosit 0-1

•Selinder -

•Epithel +1

•Bactery -

•Crystal -

8/12/2019 LapJag 8 Dan 9 Feb 2014


Clinical Picture

8/12/2019 LapJag 8 Dan 9 Feb 2014


Working Diagnosis

Constipation d.t scibala with hemorrhoid gr. I

8/12/2019 LapJag 8 Dan 9 Feb 2014


Management

Laxative

Analgetic

H2 BlockerHemorrhoid drug


8/12/2019 LapJag 8 Dan 9 Feb 2014


2. Child Alex/ 15 yo/ February 8th 2014 at

18.00

Chief complain: Right elbow painHistory :

± 15 minutes before admission, patient was riding amotorcycle. Helmet (-). And then crushed by other motorcyclefrom right back. Unconsiousness (-), vomit (-), nose/ear/mouthbleeding (-/-/-), seizure (-). His chin and chest was hit the roadand his right elbow folded.

8/12/2019 LapJag 8 Dan 9 Feb 2014


Primary Survey

• Clear, gurgling (-), snoring (-)A

• Clear, RR=20 bpm, symmetricrespiratory movement, symmetric

VBSB

• BP : 120/70 mmHg• Pulse rate : 90 bpm, reguler, strong

lifted, CRT < 2 sec.

C

•GCS E4V5M6, round and symmetricpupils diameter (3mm/3m), light

reflexes (+/+), no paralysisD

8/12/2019 LapJag 8 Dan 9 Feb 2014


A -

M -

P -

L 4 hours before

admission

E On the road

8/12/2019 LapJag 8 Dan 9 Feb 2014


Secondary Survey

•Eye : Anemic conjunctivae (-/-), icteric sclera (-/-)

•Mouth : Wet mucose

•Neck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)

Head/Neck

• I : Symmetric respiratory movement, lesion (-)

• P : Symmetric VF

• P : Sonor in all lung field

• A : symmetric VBS, Rh (-/-), Wh (-/-)Chest

• I : lesion (-), distension (-)

• A : Normal bowel sound

• P : H/L/M not palpable, tenderness (-), mass (-)

• P : Tympanic in all quadrantsAbdomen

• Warm peripher (+), edema (-) parese ( - / - ), other see statuslocalis, swelling (-) Extremities

8/12/2019 LapJag 8 Dan 9 Feb 2014


8/12/2019 LapJag 8 Dan 9 Feb 2014


Local Status

Cubiti Dextra

• L: Hematome (+), Swelling

(+), deformitas (-)

• F: Tenderness (-),

crepitation (-), distal

sensibility (+)

• M: ROM limited due to

pain

8/12/2019 LapJag 8 Dan 9 Feb 2014


Chest X-Ray

8/12/2019 LapJag 8 Dan 9 Feb 2014


Right Hand X-Ray

8/12/2019 LapJag 8 Dan 9 Feb 2014


Working Diagnose

• Soft Tissue Swelling at right cubiti

8/12/2019 LapJag 8 Dan 9 Feb 2014


Management

• Analgetic IV

• Rontgent Thorax and Right Cubiti

• Co. Orthopedic

• Oral analgetic

• Discharge by permission

8/12/2019 LapJag 8 Dan 9 Feb 2014


3. Child Ida Ariani/ 16 yo/ February 8th 2014 at

18.00

Chief complain: Pain at left arm and left kneeHistory :

± 15 minutes before admission, patient was riding amotorcycle. Helmet (-). And then crushed by other motorcycle.Unconsiousness (-), vomit/nausea (-/-), nose/ear/mouthbleeding (-/-/-), seizure (-). Patient complaint pain at left armand left knee.

8/12/2019 LapJag 8 Dan 9 Feb 2014


Primary Survey

• Clear, gurgling (-), snoring (-)A

• Clear, RR=20 bpm, symmetricrespiratory movement, symmetric

VBSB

• BP : 120/80 mmHg• Pulse rate : 80 bpm, reguler, strong

lifted, CRT < 2 sec.

C

•GCS E4V5M6, round and symmetricpupils diameter (3mm/3m), light

reflexes (+/+), no paralysisD

8/12/2019 LapJag 8 Dan 9 Feb 2014


A -

M -

P -

L -

E On the road

8/12/2019 LapJag 8 Dan 9 Feb 2014


Secondary Survey

•

Eye : Anemic conjunctivae (-/-), icteric sclera (-/-) other seestatus localis

•Mouth : Wet mucose

•Neck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)

Head/Neck

• I : Symmetric respiratory movement, lesion (-)

• P : Symmetric VF• P : Sonor in all lung field

• A : symmetric VBS, Rh (-/-), Wh (-/-)

Chest

• I : lesion (-), distension (-)

•

A : Normal bowel sound• P : H/L/M not palpable, tenderness (-), mass (-)

• P : Tympanic in all quadrantsAbdomen

• Warm peripher (+), edema (-) parese ( - / - ),other see statuslocalis Extremities

8/12/2019 LapJag 8 Dan 9 Feb 2014


Clinical Picture

L l S

8/12/2019 LapJag 8 Dan 9 Feb 2014


Local Status

Left wrist Region

L: swelling (+), deformitas

(+)

F: pain (+), crepitation (+)

M: ROM limited due topain

L l S

8/12/2019 LapJag 8 Dan 9 Feb 2014


Local Status

Mentalis RegionL: Vulnus laceratum (+)

size 1x1 cm, bleeding (-)

F: pain (+), crepitation (-)

L l S

8/12/2019 LapJag 8 Dan 9 Feb 2014


Local Status

Knee RegionL: Swelling(+)

hematome(-)

F: tenderness (+),crepitation (-)

M: ROM Limited

8/12/2019 LapJag 8 Dan 9 Feb 2014


8/12/2019 LapJag 8 Dan 9 Feb 2014


Chest X-Ray

8/12/2019 LapJag 8 Dan 9 Feb 2014


Left Forearm X-Ray

8/12/2019 LapJag 8 Dan 9 Feb 2014


Pelvic X-Ray

8/12/2019 LapJag 8 Dan 9 Feb 2014


Left Femur X-Ray

8/12/2019 LapJag 8 Dan 9 Feb 2014


X-Ray

Left Knee JointLeft Ankle Joint

8/12/2019 LapJag 8 Dan 9 Feb 2014


Working Diagnose

Closed Fracture at left ulna distal third transvere

displace + close fracture at left tibial spine

Meyer Mc.Kiever II + multiple excoriation

8/12/2019 LapJag 8 Dan 9 Feb 2014


8/12/2019 LapJag 8 Dan 9 Feb 2014


4. Mrs. Herawati/ 31 yo/ February 8th 2014 at

18.20

Chief complain: Pain at right lower abdomenHistory :

Since 1 days before admission, the patient felt pain at her right

lower abdomen continuously and more intense. Initially the

pain was felt at the epigastric region, and then it moved and

remained at the right lower abdomen. History of nausea (+),vomiting (+), constipation since 4 days ago. Urinating within

normal limit.

8/12/2019 LapJag 8 Dan 9 Feb 2014


General Status

Awareness: alert

GCS15 : E4V5M6

Vital sign

• BP : 100/70 mmHg

• HR : 76 t/m

•

RR : 18 t/m• T : 37,3 oC

8/12/2019 LapJag 8 Dan 9 Feb 2014



•Eyes : No anemic conjunctivae, icteric sclerae (-),

•Nose : No epistaxis



Head/Neck


•P : symmetric VF (+/+)

•P : sonor at all lung field

•A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)Chest



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

rebound tenderness (+)•P : Tympani

Abdomen



8/12/2019 LapJag 8 Dan 9 Feb 2014



• Local status :

–

At abdominal region :supple, distension (-),

bowel sound normal,

tenderness(+) at mc

burney point, rebound

tenderness (+), timpany

– ALVARADO score : 8

8/12/2019 LapJag 8 Dan 9 Feb 2014


Digital Rectal Examination

Look

•

Mass (-)• Abration (-)

• Hemoroid (-)

• Oedem (-)

• Eritema (-)

Feel

•

Normal analsphinctertone

• Smooth

mucosa• Tenderness

in 9 hour

Handschoon

•

Feces (+)• Mucus (-)

• Blood (-)

Clinical Picture

8/12/2019 LapJag 8 Dan 9 Feb 2014


Clinical Picture

8/12/2019 LapJag 8 Dan 9 Feb 2014


Laboratory Findings

• Haemoglobin: 11,6• WBC: 14,7

• RBC: 4,00

•

Hematocrit: 34,6• PLT: 349

• SGOT/SGPT: 22/19

•

Ur/Cr: 32/1,1

8/12/2019 LapJag 8 Dan 9 Feb 2014


8/12/2019 LapJag 8 Dan 9 Feb 2014


Working Diagnose

Susp.Acute Appendicitis

8/12/2019 LapJag 8 Dan 9 Feb 2014


8/12/2019 LapJag 8 Dan 9 Feb 2014


5. Baby Nilna Muna/ 10 months/ February 8th

2014 at 19.10

Chief complain: Wound at left tight and legHistory :

± 30 minutes before admission, patient was spilled by hot

water at left tight and left leg. History of trauma (-)

8/12/2019 LapJag 8 Dan 9 Feb 2014


General Status

Awareness: alert

GCS15 : E4V5M6

Vital sign

• HR : 140 t/m

• RR : 32 t/m

•

T : 36,7

o

C

8/12/2019 LapJag 8 Dan 9 Feb 2014



•Eyes : No anemic conjunctivae, icteric sclerae (-),

•Nose : No epistaxis



Head/Neck




•A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)Chest



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

•P : Tympani

Abdomen



8/12/2019 LapJag 8 Dan 9 Feb 2014



• Local status :

– At right wrist region :Burn injury gr. IIA

0,5%


8/12/2019 LapJag 8 Dan 9 Feb 2014



• Left Tight : burn injury

Gr. IIA 1,5 %• Left leg : burn injury

Gr. IIA 0,5%

• Dorsum foot : burn

injury Gr.IIA 1%

8/12/2019 LapJag 8 Dan 9 Feb 2014


Working Diagnose

Burn Injury at right wrist, left tight, left leg and

left foot Gr.IIA 3,5%

8/12/2019 LapJag 8 Dan 9 Feb 2014


h i i/ / b 9 h 20

8/12/2019 LapJag 8 Dan 9 Feb 2014


6. Mr. Fahruzzaini/ 54 yo/ February 9th 2014 at

06.30

Chief complain: abdominal painHistory :

since ±2 days before admission, patient complaint cant do

micturition. Patient also complaint abdominal pain and difficult

to defecation. Difficult to urinate, decrease stream (-), Bloody

urinate (-), sandy urinate (-), stone urinate (-). History ofconsumption pain relievers for 1 year. Trauma (-).

8/12/2019 LapJag 8 Dan 9 Feb 2014


General Status

Awareness: alert

GCS15 : E4V5M6

Vital sign

• BP : 90/60 mmHg

• HR : 140 t/m

• RR : 32 t/m

• T : 36,7 oC

h i l i i

8/12/2019 LapJag 8 Dan 9 Feb 2014


Physical Examination•Toxic face

•

Eyes : No anemic conjunctivae, icteric sclerae (-),•Nose : No epistaxis



Head/Neck




•A : symmetric VBS+/+, rhonchi (+/-), wheezing (-/-)Chest

• I : convex, distention (+)

•A : decrease Bowel sound

•P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (+) ,rebound tenderness (+)

•P : Tympani

Abdomen



8/12/2019 LapJag 8 Dan 9 Feb 2014



• Local status :

Convex, distention (+),tenderness(+), Rebound

tenderness (+),

decrease bowel sound

8/12/2019 LapJag 8 Dan 9 Feb 2014


Clinical Picture

8/12/2019 LapJag 8 Dan 9 Feb 2014


DRE

Look

• Mass (-)

• Abration (-)

• Hemoroid(-)

• Oedem (-)• Eritema (-)

Feel

• Weak anal

sphinctertone

• Smooth

mucosa

Handschoon

• Feces (+)

• Mucus (-)

• Blood (-)

8/12/2019 LapJag 8 Dan 9 Feb 2014


Laboratory Findings

•Haemoglobin: 12,1

• WBC: 7,0

• RBC: 4,11

•

Hematocrit: 34,9• PLT: 479

• SGOT/SGPT: 55/24

• Cr: 5,8

8/12/2019 LapJag 8 Dan 9 Feb 2014


Abdomen X-Ray

8/12/2019 LapJag 8 Dan 9 Feb 2014


Working Diagnose

Diffuse peritonitis d.t susp. Gastric perforation +

CKD gr. V

8/12/2019 LapJag 8 Dan 9 Feb 2014


Management

IV Line

Antibiotic

Analgetic

Laboratory check

Co. Digestive

DiureticEmergency Hemodialysis

Hospitalized in ICU post hemodialysis

8/12/2019 LapJag 8 Dan 9 Feb 2014


LapJag 8 Dan 9 Feb 2014

Documents