morning report 22 december

8/10/2019 Morning Report 22 December

1/96

Emergency

Report

December 22

nd

-

2

3

rd

,

20

14

Chief on duty:Adit

Resident on duty:dr. Alma Wijaya

Team:

Pras, Erika, Strata, Lucky, Nida, Vista


2/96

Minor surgery : 2

Oncology surgery :

Digestive surgery :

Thorax cardiovascular surgery :

Plastic surgery :

Urology surgery : 3

Neurosurgery : 1

Pediatric surgery :

Orthopedic : 1

Total : 7

PATIENT LIST


3/96

Patients ListNo Identity Admission to

E.R.

Diagnosis Management

1 Mr. Fajar, 26

yo/

December

22nd, 2014at 15.15

Severe Head Injury

GCS E2 Vx M5+Cerebral contusion

+ SAH+ Susp.

Fracture Basis

Cranii Fossa

Anterior Et Media +

left Pulmonarycontusion+ Closed

Fracture of right

Femur Midle 3rd

Cominutive

Displaced+ Closed

Fracture rightDistal End Radius

fryckman type III

Consult to neurology surgery:

-Obsv. Vital sign-Head up 30 degree

-IVFD NS 2500cc/24 hours

-Antibiotic

-H2 Blocker

-Analgetic

-Hospitalized ICUConsult 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


4/96


E.R.


2.

3.

Mr. Rizkian

12 yo/

Mr. Arkasi 61

yo/

December

22nd2014 at18.05

December

22nd2014 at

18.40

Lacerated wound

at right antebrachiiregion

Obsv. Scrotal masse.c susp inguinal

bladder hernia (

post Hernioraphy)

Debridement

ATSPrimary Suture

Oral Med:

Antibiotic

Analgetic

H2 Blocker

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


5/96


E.R.


4. Mr. Rusbani

50 yo/

December

22nd2014at 21.00

Fistula Vesico

Cutaneus postopen

prostatectomy +

Anemia +

Trombositopeni +

hypoalbunemia+severe Sepsis

Co Urology surgery:

Observation of Vital Sign

O2 6 lpm

IVFD Rl : D5 3:1 2000cc/day

Antibiotic

AnalgeticH2 Blocker

Blood Transfution 2 kolf

Albumin injection


6/96


E.R.


5.

6.

Mr. Samsul

Bahri 45yo/

Mr.

Mulyana 55yo/

December

22nd2014at 22.30

December

22

nd

2014at 22.55

Mild head injury

GCS 15 +lacerated wound

at right

periorbita region

+ lacerated

wound at rightknee region

Post Open

Cystotomy d.t

Susp Stricture

Uretra Posterior

IVFD RL

DebridementATS

Primary Suture

Oral Med:

Antibiotic

AnalgeticH2 Blocker

IV Line

Antibioticanalgetic

H2 blocker

Co Urologist surgery:

Pro BVUC


7/96


E.R.


7. Mr. Samuel

Salodong31 yo/

December

23rd 2014at 02.15

Closed fracture

of the right tibiadistal third (intra

artikular)

comminutive

displaced

Consult to Ortopaedy

Posterior slabAnalgetic

H2 Blocker

Pro ORIF elective


8/96

1. Mr. Fajar, 26 yo/ December 22nd, 2014 at

15.15

Chief complain: Decreased of consciousness

History : 15 hours before admissions, when pts was riding

his motorcycle while drunk. Pts lose his balanced and fell

to the ground. His head and chest were bumped to the

road. History of fainting +, vomiting (-), bleeding fromear/mouth/nose (+/+/+), pts helped by pedestrians, and

brought to Tamiang Layang Hospital. There they foud

deformity on his right hand and leg, so he were treated

with spalc. Then pts referred to Ulin Hospital for furthertreatment.


9/96

Primary Survey

Clear (-) with ETT , snoring (-), gurgling(+), stridor (-)

A Clear, RR : 30 tpm, simetric respiratory movement, VBS simetry,

Rh -/+ deep and quick

B Pulse 136 tpm, reguler, lift strong, the extremities warm

BP: 100/70 mmHgC

GCS E2VxM5, P 3mm/3mm, light reflex +/+, parese -/-D


10/96

Secondary Survey Eyes : racoon eyes (+/+), anemic conjungtivae (+/+), icteric sclerae (-/-)

Nose : rhinohargia (+) Ear : otohargia (+), battle sign (+)

Mouth : wet mucosa

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

Head/Neck

I : symmetric respiratory movement, lesion (+) a/r hemithorax sinistra

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

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

Chest

I : distention (-)

A : normal Bowel sound

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

rebound tenderness (-) P : Tympani

Abdomen

Warm, see status localizedExtremities


11/96

(-)A

IVFD rl,Analgetic, antibiotic, piracetam, anticoagulant

M

(-)P

20 hours before admissionL

On the roadE


12/96

Localized Status


13/96

Localized Status

a/r femur dextra:L: edem (+), deformity (+), angulation

(+)

F: F movement (+)

M: limited


14/96

Localized Status

a/r cruris sinistra:

L: wound (+), edem (+), deformity (-)

F: Crepitation (-)

M: ROM active


15/96

Localized Status

a/r cruris dextra:

L: wound (+), edem (+), deformity (-)

F: crepitation (-)

M: ROM limited


16/96

Localized Status

a/r antebrachii dextra:

L: edem (+), deformity

(+), angulation (+)

F: crepitation (+)

M: ROM limited


17/96

Localized Status

a/r Capitis:L: racoon eyes (+),

otohargia (+), Rhinohargia

(+)

Hematom (-), batlle sign (-)

F: crepitation (-)


18/96

Cervical X-Ray December, 22nd 2014


19/96

Thorax X-RayDecember, 22nd 2014


20/96

Femur X-ray

December, 22nd 2014

Antebrachii X-ray

December, 22nd

2014


21/96

Pelvic X-ray December, 22nd 2014


22/96

Ct Scan December, 22nd 2014


23/96

13,5

23

LABORATORY FINDING

HEMATOLOGY

Parameter Result Normal Value

December 22nd, 2014

Hemoglobin 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 0,7-1,4 mg/dL

GDP 135


24/96

24

PEMERIKSAAN HASIL RUJUKAN SATUAN

PT

12,39,9-13,5 dtk

INR 1,08

Control Normal PT 11,4

APTT 20,8 22,2-37 dtk U/I

Control Normal APTT 26,1


25/96

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 FemurMidle 3rd Cominutive Displaced+ Closed

Fracture right Distal End Radius fryckman

type III


26/96

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


27/96

Chief Complain : Wounded hand

History :

an hours before admission, pts fell at his home while

carring a plate. The plate became broken and itswounded 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.

Suri/ 50 Yo/1-11-55-772. Mr. Rizkian 12 yo/ December 22nd2014 at

18.05


28/96

Primary Survey

Clear (-), snoring (-), gurgling(+), stridor (-)


Rh -/-, wh -/-


BP: 110/70 mmHgC

GCS E4V5M6, P 3mm/3mm, light reflex +/+, parese -/-D


29/96

Secondary Survey Eyes : anemic conjungtivae (-/-), icteric sclerae (-/-)

Nose : epitaksis (-)

Ear : otohargia (-), battle sign (-)

Mouth : wet mucosa


Head/Neck

I : symmetric respiratory movement

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

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

Chest

I : distention (-)


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

rebound tenderness (-) P : Tympani

Abdomen

Warm, parese (-/-), see status localizedExtremities


30/96

(-)A

(-)M

(-)P

An hour before admissionL

At homeE


31/96

Clinical Pictures


32/96

Localized Status

a/r antebrachii:

L: edem (-), deformity (-), wound (+),

size diameter 5 cm, base wound fascia

(+)

F: tenderness (-), crepitation (-), pain

(+)M: ROM Active


33/96

Post hecting


34/96

Working Diagnosis

Lacerated wound at right antebrachii region


35/96

Management

Debridement

ATS

Primary SutureOral Med:

Antibiotic

AnalgeticH2 Blocker


36/96

Chief Complain : bump at scrotum

History :

since one year before admission, pts complaint that

there was a bump on his left scrotum. At thebegining, 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 duranteoperation, hernia sach wasnt found. The operation

back then was imidiately stop. Pts then brought to Ulin

Hospital for further examination.

Suri/ 50 Yo/1-11-55-773. Mr. Arkasi 61 yo/ December 22nd2014 at

18.40


37/96

Physical Examination

Compos Mentis

BP: 130/100mmhg

P: 82 tpm

RR: 20 tpm

T: 36,6 C


38/96

38

I : wound (-/-), hematome (-/-)

P : mass (-/-), tenderness (-/-)

CVA

I : mass (-/-), hematome (-/-), wound (-/-)

P: mass , tenderness (-/-)

Flank Area

I: improminent urinary bladder, wound (-), hematome (-), mass(+)

P : tenderness (+)

Suprapubic

OUE : bloody discharge (-), edema (-), stone (-)

Genitalia


39/96

Clinical Picture


40/96

a/r scrotum and inguinal:

L: mass (+), size diameter 10 cm,


41/96

Mass at scrotal region

10cm in diameter

Solid consistencies

Reguler edge


42/96

Surgical wound +


43/96

Fibrosis at OUE

LABORATORY FINDING


44/96

13,5

44

LABORATORY FINDING

HEMATOLOGY


December 22nd, 2014

Hemoglobin 11,9 14,0-18,0 g/dl

Lekosit 11,7 4,0-10,5 ribu/ul


Hematokrit 36,2 42-52 vol %


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 0,7-1,4 mg/dL

GDS 272


45/96

45


PT 12,8 9,9-13,5 dtk

INR 1,11


APTT 27,6 22,2-37 dtk U/I

Control Normal APTT26,1


46/96

X-ray PelvicX-ray Abdomen


47/96

USG


48/96

USG


49/96

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


50/96

Working Diagnosis

Obsv. Scrotal Mass e.c susp Inguinal Bladder

Interna

M t


51/96

Management

Consult to digestive surgery:

Obsv. Vital sign

Co. Urology

Consult to urology:Antibiotic

H2 Blocker

Analgetic

Pro uretrocystographyIf cant urinate, DC cateter small caliber (RF)

Join treatment with digestive

4 M R b i 50 / D b 22nd


52/96

4. Mr. Rusbani 50 yo/ December 22nd

2014 at 21.00

Chief Complain : discharge fromoperation site

History :

since 7 days ago before admission, ptscomplain about his urin and blood comesout from operation site. 15 days beforeadmission, because he had BPH pts gotprostatectomy treatment at Balangan

hospital. Now, pts have complainingabout his scar from operation site andswollen at his face and foot.


53/96


Compos Mentis

BP: 130/90mmhg

P: 108 tpm

RR: 24 tpm

T: 36, C


54/96

54



CVA



Flank Area

I: improminent urinary bladder, wound (-), hematome (-), mass(-)

P : tenderness (+)

Suprapubic


Genitalia

Cli i l i t


55/96

Clinical picture


56/96


57/96


58/96

a/r abdomen

I:: Ascites, wound post op

is wet, pus (+),

A: -

P: Pain (+),Urine (+)

Palpable pain (+) a/r

suprapubicRelease pain (-)

P: Shifting dullnes (+)

LABORATORY FINDING


59/96

13,5

59

HEMATOLOGY


December 22nd, 2014Hemoglobin 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 %


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 0,7-1,4 mg/dL

GDS 161


60/96

60


Albumin 2.6 3.5-5.5 g/dl


61/96

Working Diagnosis

Fistula Vesico Cutaneus post open

prostatectomy + Anemia + Trombositopeni +

hypoalbunemia+ severe Sepsis

Management


62/96

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 M S l B h i 45 / D b 22nd


63/96

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 forfurther treatment.

Suri/ 50 Yo/1-11-55-776. Mr. Samsul Bahri 45 yo/ December 22nd

2014 at 22.30

Primary Survey


64/96

Primary Survey



Rh -/-, wh -/-


BP: 130/80 mmHgC

GCS E4V5M6, P 3mm/3mm, light reflex +/+, parese -/-D

S d S


65/96



Ear : otohargia (-), battle sign (-) Mouth : wet mucosa


Head/Neck


P : symmetric VF (+/+)

P : sonor at all lung

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

I : distention (-)


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

P : Tympani

Abdomen

Warm, parese (-/-), see status localizedExtremities


66/96

(-)A

(-)M

(-)P

12 hour before admissionL

On the RoadE


67/96

Clinical Pictures


68/96

Localized Status

a/r peri orbita dextraL: edem (+), deformity (-), wound (+), size

diameter 2 cm, base wound bone (+), active

bleeding (-)

F: tenderness (+), crepitation (-), pain (+)


69/96

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


70/96

Post hecting


71/96

Skull X-ray


72/96

Thorax X-ray


73/96

Knee X-ray


74/96

Working Diagnosis

CKR + Vulnus laxceratum a/r periorbita dextra,

genu dextra

Management


75/96

Management

IVFD RL

Debridement

ATS

Primary Suture

Oral Med:

Antibiotic

Analgetic

H2 Blocker

7 Mr Mulyana 55 yo/ December 22nd


76/96

7. Mr. Mulyana 55 yo/ December 22

2014 at 22.55

Chief Complain : Canturinate History :

2 days before admission, pts complaint that hecant urinate. Then pts seek treatment to TanahBumbu. Because he cant get to wore urincateter, he got open cystotomy. Ptscomplaining about having difficulty to urinatesince 5 days before admission. The pain from

cant urinate continously increase day afterday. History of stone voiding (-), sandy voiding(-). Pts had history of blood voiding.


77/96


Compos Mentis

BP: 130/90mmhg

P: 10 tpm

RR: 24 tpm

T: 36, C

CVA


78/96

78



CVA



Flank Area

I: improminent urinary bladder, wound (-), hematome (-), mass(-)

P : tenderness (+)

Suprapubic


Genitalia


79/96

LABORATORY FINDING


80/96

13,5

80

HEMATOLOGY


December 19nd, 2014

Hemoglobin 12.1 14,0-18,0 g/dl

Lekosit 17300 4,0-10,5 ribu/ul


Hematokrit 36 42-52 vol %Trombosit 213 150-450 ribu/ul

Ureum 49 10-50 g/dL

Creatinin 1 0,7-1,4 mg/dL

GDS 134


81/96

81


PT 4 9,9-13,5 dtk

INR 1,08


APTT 210 22,2-37 dtk U/I

Control Normal APTT 26,1

USG


82/96

USG

E i


83/96

Expertise

Conclusion:

1. Pelvicocaliectasis Ren Bilateral

2. Cystitis

3. Susp. Distal Ureter Calculy and diverticel at

left lateral vesikurinaria

4. Hyperplasia Prostat


84/96

Urine out put Cystostomy bag

W ki Di i


85/96

Working Diagnosis

Post Open Cystotomy ec Susp Strictur Uretra

Posterior

Management


86/96

g

IV Line

Antibiotic

analgetic

H2 blocker

Co Urologist surgery:Pro BVUC

Suri/ 50 Yo/1-11-55-778. Mr. Samuel Salodong 31 yo/ December 23rd


87/96

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.

Suri/ 50 Yo/1-11-55-778. Mr. Samuel Salodong 31 yo/ December 23rd

2014 at 02.15

Primary Survey


88/96

y y



Rh -/-, wh -/-B

Pulse 86 tpm, reguler, lift strong, the extremities warm

BP: 130/80 mmHgC

GCS E4V5M6, P 3mm/3mm, light reflex +/+, parese +/-D

Secondary Survey


89/96



Ear : otohargia (-), battle sign (-) Mouth : wet mucosa


Head/Neck


P : symmetric VF (+/+)

P : sonor at all lung A : symmetric VBS+/+, rhonchi (-/-), wheezing (-/-)

Chest

I : distention (-)


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

P : Tympani

Abdomen

Warm, parese (+/-), see status localizedExtremities


90/96

(-)A

(-)M

(-)P

L

E

Cli i l Pi t


91/96

Clinical Pictures

Localized Status


92/96

Localized Statusa/r cruris dextra et pedis dextra

L: edem (+), deformity (+), wound (-),angulation (+)

F: tenderness (+), crepitation (+), pain (+)

M: ROM limited

Cruris X ray


93/96

Cruris X-ray

Pedis X ray


94/96

Pedis X-ray

Working Diagnosis


95/96

Working Diagnosis

Closed fracture cruris 1/3 distal intra artikularcominutive displaced dextra

Management


96/96

Consult to Ortopaedy

Posterior slab

Analgetic

H2 Blocker

Pro ORIF elective

morning report 22 december

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