mr 20-12-14
TRANSCRIPT
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Emergency Case Report
2014 20-21
TH
December
Resident on Duty : dr. Yan AdityaChief Co-Assistant : Erina
Team :
Endah, Mira, Firdha, Dyah, Bimo, Ady
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Minor Surgery : -
Digestive Surgery : 1
Thorax Cardiovascular Surgery : -
Plastic Surgery : -
Urology Surgery : -
Neurosurgery : 5
Pediatric Surgery : -
Oncology Surgery : 1
Orthopaedy : 3
Total : 10
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No IdentityAdmission to
E.R.Diagnosis Treatment / Planning
1 Mr. Anang Rusdi/
63 y.o/ 1.13.25.81
20th
December
2014/ 15.00
Bloody feces due to rectal
tumor
T2N1M0
Complete Blood Count
IVFD RL 20 tpm
Patient discharge by permission andcontrol as outpatient
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No IdentityAdmission
to E.R.Diagnosis Treatment / Planning
2 Mr. Hendri/ 20
y.o/1.13.25.87
20th
December
2014/ 16.15
Closed fracture tibia
sinistraX-ray antebrachii sinistra AP+LAT
Patient discharge by request
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No IdentityAdmission
to E.R.Diagnosis Treatment / Planning
3 Mrs. Sarimas/
56
y.o/1.13.25.88
20th
December
2014/18.00
Complete Blood Count
CT Scan Head Trauma + Facial 3D +
Bone WindowX-ray antebrachii dextra, femur dextra,
cruris dextra
IVFD RL 20 tpm
H2 Blocker
AnalgesicAntibiotic
Folley catheter
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No IdentityAdmission
to E.R.Diagnosis Treatment / Planning
4 Ch. M. Azhar/
14 y.o/ 0-60-69-
18
20th
December
2014/ 18.40
Mild Head InjuryComplete Blood count
X-ray trauma series
IVFD RL 20 tpmH2 blocker
Analgesic
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No IdentityAdmission
to E.R.Diagnosis Treatment / Planning
5 Mr. Kadir/ 25
y.o/ 1-13-25-91
20th
December
2014/ 18.45
Mild Head Injury + susp.
Fracture Basis cranii fossa
media
Complete Blood count
CT Scan Head
IVFD NaCl 0,9% 20 tpm
O24 lpmHead up
Antibiotic
H2 blocker
Analgesic
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No IdentityAdmission
to E.R.Diagnosis Treatment / Planning
6 Mrs. Arbayah/
52 y.o/
1.13.25.90
20th
December
2014/ 17.15
X-ray Cruris dextra & Shoulder dextra
IVFD RL 20 tpm
Analgesic
Arm sling
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No IdentityAdmission
to E.R.Diagnosis Treatment / Planning
7 Mr. Sabli/ 35
y.o/ 0.72.54.13
20th
December
2014/ 20.30
Hernia Inguinalis Lateralis
Sinistra InkarserataObs. vital sign
Complete blood count
IVFD RL 20 tpmAntbiotic
Analgesic
H2 blocker
Consult to Digestive surgeon
department:Pro cito herniotomy
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No IdentityAdmission
to E.R.Diagnosis Treatment / Planning
8 Mr. Yusran/ 35
y.o/ 1.13.25.99
20th
December
2014/ 22.00
Mild Head Injury + Complete blood count
CT Scan Head
O24 lpm nasal canulFolley catheter
IVFD NaCl 2000cc/24 hours
Antibiotic
Analgesic
H2 blocker
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No IdentityAdmission
to E.R.Diagnosis Treatment / Planning
9 Ms. Norliani/ 17
y.o/ 1.13.25.95
20th
December
2014/ 20.45
Complete blood count
X-ray skull AP+LAT
Primary suture
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1. Mr. Anang Rusdi/ 63 y.o/ 1.13.25.81
20th December 2014/ 15.00
Chief Complain : Bloody feces
History: Patient complain his bloody feces since 3 months ago.
Bloody feces come intermittent and there was much blood.Patient also feel pain when defecation. Patient work as painter.
Patient said that he lost his weight gradually and become thin
since a year ago.
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General Status
Eyes : anemic conjunctiva, (-) icteric sclera (-)
Mouth : Wet mucous
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
Head/Neck
I : Symmetric respiratory movement, no retraction
P : Symmetric VF P : Sonor at all lung fields
A : symmetric VBS, rhonchi (-), no wheezing
Chest
I : Wound (-), distension (-), hematoma (-)
A : Bowel sound (+)
P : Liver/spleen/kidney not palpable, mass not palpable,tenderness (-)
P : TymphaniAbdomen
Warm extremitiesExtremities
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Clinical Picture
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Local Status
I : mass about 4 cm,
blood (+), pus (+)
P : consistency kenyal,
mobile
L b t i R lt (20 12 2014)
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Examination Result Normal value
hemoglobin 12.8 14.00-18.00 g/dl
Leucosit 8.8 4.0-10.5 Ribu/uleritrosit 4.22 4.50-6.00 juta/ul
hematocrit 37.4 42.00-52.00 Vol%
trombocit 521 150-450 Ribu/ul
RDW-CV 14.5 11.5-14.7 %
MCV 88.8 80.0-97.0 Fl
MCH 30.3 27.0-32.0 Pg
MCHC 34.2 32.0-38.0 %
Gran% 80.4 50.0-70.0 %
Limfosit% 14.3 25.0-40.0 %
MID% 5.3 3.0-9.0 %
Laboratorium Result (20-12-2014)
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Examination Result Normal value
Gran# 7.10 2.50-7.00 Ribu/ul
Limfosit# 1.3 1.25-4.0 Ribu/ul
MID# 0.4 Ribu/ulRandom Blood
Glucose
98
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Working Diagnosis
Bloody feces due to Rectal tumor
T2N1M0
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Management
Complete Blood CountIVFD RL 20 tpm
Patient discharge by permission and control
as outpatient
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2. Mr. Hendri/ 20 y.o/ 1.13.25.87
20thDecember 2014/ 16.15
Chief Complain : Pain at left hand
History: 30 minutes before admission, patient had
an accident. Patient was riding motorbike and hit
other vehicle from other side. Then patient fell to
the left side and hit his left hand.
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Primary Survey
ClearA
Clear, RR= 20 bpm, symmetric
respiratory movement, symmetricVBSB
BP : 110/70 mmHg Pulse rate :89 bpm, strong, reguler,
CRT < 2 sec.C
GCS E4V5M6, round and equalpupils diameter (3mm/3mm), light
reflexes (+/+), no paralysisD
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A -
M -
P -
L2 hours before
admission
E On the road
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Secondary Survey
Eyes : anemic conjunctiva, (-) icteric sclera (-),
Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)
Head/Neck
I : Symmetric respiratory movement, no retraction P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
Chest
I : Wound (-), distension (-), hematoma (-)
A : Bowel sound (+)
P : Liver/spleen/kidney not palpable, mass not palpable,tenderness (-)
P : Tymphani
Abdomen
Warm extremities
Extremities
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Clinical Picture
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X-ray antebrachii sinistra
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Planning Diagnose
Closed fracture tibia sinistra
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Management
X-ray antebrachii sinistra AP+LAT
IVFD RL 20 tpm
Patient discharge by request
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3. Mrs. Sarimas/ 56 y.o/1.13.25.88
20thDecember 2014/ 18.00
Chief Complain : Decreased consciousness
History: 6 hours before admission, patient had an accident.
Patient was hit by motorcycle. Patient complain that her righthand and leg pain and unable to move. Patient was treated at
Puskesmas Sembabani and got IVFD RL. Then she brought
directly to Ulin hospital for further treatment.
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Primary Survey
Clear, Snoring (-), gurgling (-),A
Clear, RR= 24 bpm, symmetric
respiratory movement, symmetricVBS, Rh (-/-) wh (-/-)B
BP : 100/60 mmHg Pulse rate : 74 bpm, reguler, strong
lifted, CRT >2 sec.C
GCS E4V4M6, round and equalpupils diameter (3mm/3m), light
reflexes (+/+), no paralysisD
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A-
M IVFD RL
P -
L 1 hours beforeadmission
E Road
S d
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Secondary survey
Head : multiple sutured woundEye : Anemic conj. (-/-), icteric sclera (-/-)Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, retraction (-),multiple vulnus escoriation (+)
P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)
Chest
I : Wound (-), distension (-)
A : Normal bowel soundP : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrantsAbdomen
Warm extremitiesExtremities
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Clinical Picture
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Local Status
a/r cruris sinistra
L: swelling (+),
deformity (+)
F: pain (+), crepitation(+)
M: ROM limited due to
pain
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Local Status
a/r antebrachii dextra
L: swelling (+),
deformity (+)
F: pain (+), crepitation(+)
M: ROM limited due to
pain
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Local Status
a/r head:
L: sutured wound (+),
swelling (+)
F: pain (+)
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CT Scan Head Trauma + Facial 3D +
Bone Window
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X-ray Antebrachii dextra AP+LAT
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X-ray femur dextra AP+LAT
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X-ray cruris dextra AP+LAT
Laboratorium Result (20-12-2014)
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Examination Result Normal value
hemoglobin 10.1 14.00-18.00 g/dl
Leucosit 8.9 4.0-10.5 Ribu/uleritrosit 3.45 4.50-6.00 juta/ul
hematocrit 30.5 42.00-52.00 Vol%
trombocit 187 150-450 Ribu/ul
RDW-CV 14.1 11.5-14.7 %
MCV 88.6 80.0-97.0 Fl
MCH 29.2 27.0-32.0 Pg
MCHC 33.1 32.0-38.0 %
Gran% 81.0 50.0-70.0 %
Limfosit% 15.3 25.0-40.0 %
MID% 3.7 3.0-9.0 %
Laboratorium Result (20 12 2014)
Examination Result Normal value
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Examination Result Normal value
Gran# 7.20 2.50-7.00 Ribu/ul
Limfosit# 1.4 1.25-4.0 Ribu/ul
MID# 0.3 Ribu/ulPT Result 12.5 9.9-13.5 Detik
INR 1.09 -
Control Normal
PT
11.4 - -
APTT Result 19.0 22.2-37.0 Detik
Control Normal
APTT
26.1 -
Random Blood
Glucose
185
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Working Diagnosis
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Management
Complete Blood Count
CT Scan Head Trauma + Facial 3D + Bone Window
X-ray antebrachii dextra, femur dextra, cruris dextra
IVFD RL 20 tpm
H2 Blocker
Analgesic
Antibiotic
Folley catheter
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4. Ch. M. Azhar/ 14 y.o/ 0-60-69-18
20thDecember 2014/ 18.40
Chief Complain :
History: 20 minutes before admission, patient had an accident
at Kuripan. Patient admit that he hit person when across the
road. When patient try to avoid that person, he fell from his
motorcycle. His mouth got blunt trauma. Patient use helmet
when riding. History of unconscious (-), vomit (-), blood from
mouth/nose/ear (+/+/-).
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Primary Survey
Clear, Snoring (-), gurgling (-),A
Clear, RR= 24 bpm, symmetric
respiratory movement, symmetricVBS, Rh (-/-) wh (-/-)B
BP : 110/60 mmHg Pulse rate : 88 bpm, reguler, strong
lifted, CRT >2 sec.C
GCS E4V5M6, round and equalpupils diameter (3mm/3m), light
reflexes (+/+), no paralysisD
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A -
M -
P -
L 1 hours beforeadmission
E Road
Secondary survey
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Secondary survey
Eye : Anemic conj. (-/-), icteric sclera (-/-)
Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, retraction (-)
P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)
Chest
I : Wound (-), distension (-), vulnus escoriation (-)
A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrantsAbdomen
Warm extremitiesExtremities
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Clinical Picture
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X-ray Skull AP+LAT
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X-ray Cervical AP+LAT
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X-ray Thorax AP
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X-ray Pelvis
Laboratorium Result (20-12-2014)
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Examination Result Normal value
hemoglobin 13.5 14.00-18.00 g/dl
Leucosit 19.7 4.0-10.5 Ribu/ul
eritrosit 5.91 4.50-6.00 juta/ul
hematocrit 40.8 42.00-52.00 Vol%
trombocit 279 150-450 Ribu/ul
RDW-CV 15.1 11.5-14.7 %MCV 69.2 80.0-97.0 Fl
MCH 22.8 27.0-32.0 Pg
MCHC 33.0 32.0-38.0 %
Gran% 84.2 50.0-70.0 %
Limfosit% 8.7 25.0-40.0 %
MID% 7.1 3.0-9.0 %
( )
Examination Result Normal value
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Gran# 16.60 2.50-7.00 Ribu/ul
Limfosit# 1.7 1.25-4.0 Ribu/ul
MID# 1.4 Ribu/ul
PT Result 11.3 9.9-13.5 Detik
INR 0.99 -
Control Normal
PT
11.4 - -
APTT Result 21.9 22.2-37.0 Detik
Control Normal
APTT
26.1 -
Random Blood
Glucose
131
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Working Diagnosis
Mild Head Injury
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Management
Complete Blood Count
X-ray trauma series
IVFD RL 20 tpm
H2 blocker
Analgesic
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5. Mr. Kadir/ 25 y.o/ 1-13-25-91
20thDecember 2014/ 18.45
Chief Complain : Bleeding from left ear
History: One hour before admission, patient had an accident
when he was riding motorcycle. Helmet (+). In Kayutangi he
was hit by another motorcycle, he fell and his head hit the
ground. History of unconsciousness (-), history of vomiting (+),
history of bleeding from ear (+), nose (+), mouth (-). He was
brought by civilian to Ulin general hospital.
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Primary Survey
Clear, Snoring (-), gurgling (-),A
Clear, RR= 22 bpm, symmetric
respiratory movement, symmetricVBS, Rh (-/-) wh (-/-)B
BP : 120/90 mmHg Pulse rate : 85 bpm, reguler, strong
lifted, CRT >2 sec.C
GCS E3V5M5, round and equalpupils diameter (3mm/3m), light
reflexes (+/+), no paralysisD
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A -M -
P -
L
3 hours before
admission
E On the road
Secondary survey
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Secondary survey
Vulnus escorea e/r supra orbita sinistra 1 cmVulnus escorea e/r zygoma dextra 3 cmVulnus escorea e/r 10x2 cmEye : Anemic conj. (-/-), icteric sclera (-/-)Ear : otthorea (+)Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, retraction (-) P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)
Chest
I : Wound (-), distension (-), vulnus escoriation (-)
A : Normal bowel soundP : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrants
Abdomen
Warm extremities e/r antebrachii dextra: vulnus escorea 2 x 5 cm e/r genu sinistra vulnus escorea multiple
e/r digiti 345 pedis sinistra: vulnus escorea multiple
Extremities
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Clinical Picture
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Local Status
a/r head
Vulnus escoriatum(+)
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Local Status
a/r ear
L: blood (+)
Laboratorium Result (20-12-2014)
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Examination Result Normal value
hemoglobin 14.8 14.00-18.00 g/dl
Leucosit 10.4 4.0-10.5 Ribu/ul
eritrosit 5.49 4.50-6.00 juta/ul
hematocrit 43.9 42.00-52.00 Vol%
trombocit 217 150-450 Ribu/ul
RDW-CV 15.0 11.5-14.7 %MCV 80.0 80.0-97.0 Fl
MCH 26.9 27.0-32.0 Pg
MCHC 33.7 32.0-38.0 %
Gran% 78.5 50.0-70.0 %
Limfosit% 15.2 25.0-40.0 %
MID% 6.3 3.0-9.0 %
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CT Scan Head
Examination Result Normal value
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Gran# 8.20 2.50-7.00 Ribu/ul
Limfosit# 1.6 1.25-4.0 Ribu/ul
MID# 0.6 Ribu/ul
PT Result 9.5 9.9-13.5 Detik
INR 0.84 -
Control Normal
PT
11.4 - -
APTT Result 21.7 22.2-37.0 Detik
Control Normal
APTT
26.1 -
Random Blood
Glucose
130
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Working Diagnosis
Mild Head Injury + susp. Fracture Basis cranii fossa media
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Management
Complete Blood count
CT Scan Head
IVFD NaCl 0,9% 20 tpm
O24 lpm
Head up
Antibiotic
H2 blocker
Analgesic
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6. Mrs. Arbayah/ 52 y.o/ 1.13.25.90
20thDecember 2014/ 17.15
Chief Complain :
History:
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Primary Survey
Clear, Snoring (-), gurgling (-),A
Clear, RR= 22 bpm, symmetricrespiratory movement, symmetric
VBS, Rh (-/-) wh (-/-)B
BP : 120/90 mmHg Pulse rate : 92 bpm, reguler, strong
lifted, CRT >2 sec.C
GCS E3V5M5, round and equalpupils diameter (3mm/3m), light
reflexes (+/+), no paralysisD
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A -M
IVFD RL 20 tpm, Inj.Ketorolac 30 mg
P -
L
4 hours before
admission
E On the road
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Clinical Picture
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Local Status
a/r cruris dextra
L: swelling (+), open
wound (-)
F: pain (+), crepitation(+)
M: ROM limited due to
pain
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Local Status
a/r clavicula dextra
L: swelling (-)
F: pain (+), crepitation
(+) M: ROM limited due to
painS
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X-ray cruris dextra
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X-ray clavicula dextra
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Working Diagnosis
Fraktur tibia fibula + clavicula dextra
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Management
X-ray Cruris dextra & Shoulder dextra
IVFD RL 20 tpm
Analgesic
Arm sling
Posterior slab
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After Posterior slab & Arm sling
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7. Mr. Sabli/ 35 y.o/ 0.72.54.13
20thDecember 2014/ 20.30
Chief Complain : Lumph in groin
History: 4 hours before admission to hospital, patient complain
about lumph in groin that cantget in. The lumph was appear
since 5 months ago but never stay. The lumph can get bigger
and swollen by itself. The lumph get bigger when he work sohard or lift something weight. Patient work as labour.
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Vital Sign
BP : 120/80 mmHg
PR : 72 bpm
RR : 18 tpm
T : 36,7oC
General Status
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Eye : Anemic conj. (-/-), icteric sclera (-/-)
Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, retraction (-) P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)
Chest
I : Wound (-), distension (-), vulnus escoriation (-)
A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrantsAbdomen
Warm extremitiesExtremities
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Clinical Picture
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Local Status
a/r inguinal et scrotalis
sinistra
Mass 10 cm
Bowel sound (+)
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Rectal Toucher
TSA strong
Ampulla isnt collapse
Mass (-)
NT (-)
Mukosa licin
Feces (+), blood (-)
Examination Result Normal value
Laboratorium Result (20-12-2014)
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Examination Result Normal value
hemoglobin 10.1 14.00-18.00 g/dl
Leucosit 20.8 4.0-10.5 Ribu/ul
eritrosit 4.02 4.50-6.00 juta/ul
hematocrit 30.9 42.00-52.00 Vol%
trombocit 351 150-450 Ribu/ul
RDW-CV 15.4 11.5-14.7 %MCV 77.1 80.0-97.0 Fl
MCH 25.1 27.0-32.0 Pg
MCHC 32.6 32.0-38.0 %
Gran% 82.2 50.0-70.0 %
Limfosit% 10.5 25.0-40.0 %
MID% 7.3 3.0-9.0 %
Examination Result Normal value
Gran# 17 10 2 50-7 00 Ribu/ul
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Gran# 17.10 2.50 7.00 Ribu/ul
Limfosit# 2.2 1.25-4.0 Ribu/ul
MID# 1.5 Ribu/ul
PT Result 12.5 9.9-13.5 Detik
INR 1.09 -
Control Normal
PT
11.4 - -
APTT Result 22.5 22.2-37.0 Detik
Control Normal
APTT
26.1 -
Random Blood
Glucose
200
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Working Diagnosis
Hernia Inguinalis Lateralis Sinistra Inkarserata
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Management
Obs. vital sign
Complete blood count
IVFD RL 20 tpm
Antbiotic
Analgesic
H2 blocker
Consult to Digestive surgeon department: Pro cito herniotomy
8 M Y / 32 / 1 13 2 99
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8. Mr. Yusran/ 32 y.o/ 1.13.25.99
20thDecember 2014/ 22.00
Chief Complain : Pain in face
History: 5 hours before admission patient had an accident.
Mechanism of trauma was unknown. Patient was brought by
police officer to Ratu Zalecha hospital. History of
unconsciousness (-), history of vomiting (-), history of bleedingfrom mouth/ear/nose (+/+/+). Patient then refer to Ulin hospital
for further treatment.
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Primary Survey
Clear, Snoring (-), gurgling (-),A
Clear, RR= 22 bpm, symmetricrespiratory movement, symmetric
VBS, Rh (-/-) wh (-/-)B
BP : 120/90 mmHg Pulse rate : 92 bpm, reguler, strong
lifted, CRT >2 sec.C
GCS E3V5M5, round and equalpupils diameter (3mm/3m), light
reflexes (+/+), no paralysisD
A -
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M
IVFD NaCl 20 tpm +
tramadol, Inj.Ketorolac 30 mg, Inj.
Kalnex, Inj. Piracetam,Inj. Ranitidin, Inj.
ceftriaxone
P -
L 2 hours beforeadmission
E On the road Secondary survey
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Disk face (+)L: Open wound a/r supra orbita dextra 5 x 1 cm.based on bone
F: crepitation (+)Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, retraction (-) P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)
Chest
I : Wound (-), distension (-), vulnus escoriation (-),jejas (+)
A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrantsAbdomen
Warm extremitiesExtremities
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Clinical Picture
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CT Scan Head
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X-ray cruris sinistra
Examination Result Normal value
Laboratorium Result (20-12-2014)
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hemoglobin 15.1 14.00-18.00 g/dl
Leucosit 21.9 4.0-10.5 Ribu/ul
eritrosit 4.86 4.50-6.00 juta/ul
hematocrit 43.6 42.00-52.00 Vol%
trombocit 229 150-450 Ribu/ul
RDW-CV 14.8 11.5-14.7 %
MCV 89.8 80.0-97.0 Fl
MCH 31.0 27.0-32.0 Pg
MCHC 34.6 32.0-38.0 %
Gran% 85.1 50.0-70.0 %Limfosit% 8.0 25.0-40.0 %
MID% 6.9 3.0-9.0 %
Examination Result Normal value
Gran# 18.60 2.50-7.00 Ribu/ul
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Limfosit# 1.8 1.25-4.0 Ribu/ul
MID# 1.5 Ribu/ul
PT Result 11.4 9.9-13.5 Detik
INR 1.00 -
Control Normal
PT
11.4 - -
APTT Result 23.2 22.2-37.0 Detik
Control Normal
APTT
26.1 -
Random Blood
Glucose
154
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Working Diagnosis
Mild Head Injury + fracture ??
M t
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Management
Complete blood count CT Scan Head
X-ray cruris sinistra
O24 lpm nasal canul Folley catheter
IVFD NaCl 2000cc/24 hours
AntibioticAnalgesic
H2 blocker
9 Ms Norliani/ 17 y o/ 1 13 25 95
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9. Ms. Norliani/ 17 y.o/ 1.13.25.95
20thDecember 2014/ 20.45
Chief Complain :
History: Post KLLD
P i S
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Primary Survey
Clear, Snoring (-), gurgling (-),A
Clear, RR= 22 bpm, symmetricrespiratory movement, symmetric
VBS, Rh (-/-) wh (-/-)
B
BP : 120/90 mmHg Pulse rate : 92 bpm, reguler, strong
lifted, CRT >2 sec.C
GCS E4V5M6, round and equalpupils diameter (3mm/3m), light
reflexes (+/+), no paralysisD
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A -
MIVFD RL 20 tpm, Inj.
Ketorolac 30 mg
P -
L4 hours before
admission
E On the road
Secondary survey
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Eye : Anemic conj. (-/-), icteric sclera (-/-)
Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, retraction (-) P : Symmetric VF P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)Chest
I : Wound (-), distension (-), vulnus escoriation (-)
A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrantsAbdomen
Warm extremitiesExtremities
Cli i l Pi t
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Clinical Picture
L l St t
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Local Status
a/r parietal
X Sk ll AP+LAT
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X-ray Skull AP+LAT
Examination Result Normal value
Laboratorium Result (20-12-2014)
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hemoglobin 13.3 14.00-18.00 g/dl
Leucosit 15.2 4.0-10.5 Ribu/ul
eritrosit 4.76 4.50-6.00 juta/ul
hematocrit 40.1 42.00-52.00 Vol%
trombocit 186 150-450 Ribu/ul
RDW-CV 12.7 11.5-14.7 %
MCV 84.4 80.0-97.0 Fl
MCH 27.9 27.0-32.0 Pg
MCHC 33.1 32.0-38.0 %
Gran% 80.3 50.0-70.0 %Limfosit% 12.3 25.0-40.0 %
MID% 7.4 3.0-9.0 %
Examination Result Normal value
Gran# 12.20 2.50-7.00 Ribu/ul
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Limfosit# 1.9 1.25-4.0 Ribu/ul
MID# 1.1 Ribu/ul
PT Result 9.0 9.9-13.5 Detik
INR 0.80 -
Control Normal
PT
11.4 - -
APTT Result 19.6 22.2-37.0 Detik
Control Normal
APTT
26.1 -
SGOT 31 0-46 U/I
SGPT 22 0-45 U/IUrea 17 10-50 Mg/dL
Creatinine 0.6 0.7-1.4 Mg/dL
Working Diagnosis
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Working Diagnosis
Mild Head Injury
Management
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Management
Complete blood count X-ray skull AP+LAT
Primary suture
10 Mr Zaini/ 20 y o/ 1 13 26 06
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10. Mr. Zaini/ 20 y.o/ 1.13.26.06
21thDecember 2014/ 01.20
Chief Complain : Bleeding from nose
History: 6 hours before admission, patient had an accident.
Patient had an open wound on head and fracture of right hand.
History of unconsciousness (-), history of vomiting (-), bleedingfrom nose (+).
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A -
MIVFD RL, Inj. Ketorolac30 mg, Inj. Cefotaxime,
Inj. ranitidin
P -
L6 hours before
admission
E On the road
Secondary survey
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Eye : Anemic conj. (-/-), icteric sclera (-/-)
Mouth : wet mucousNeck : JVP enhancement (-/-), lymphatic nodesenlargement (-/-)
Head/Neck
I : Symmetric respiratory movement, retraction (-) P : Symmetric VF
P : Sonor in all lung field A : Symmetric VBS, Rh (-/-), Wh (-/-)Chest
I : Wound (-), distension (-), vulnus escoriation (-)
A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).P : Tympanic in all quadrants
Abdomen
Warm extremitiesExtremities
Clinical Picture
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Clinical Picture
Local status
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Local status
a/r frontal
Local Status
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Local Status
a/r antebrachii dextra
L: swelling (+),
deformity (+)
F: pain (+), crepitation(+)
M: ROM limited due to
pain
X ray Thorax AP
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X-ray Thorax AP
X ray skull AP+LAT
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X-ray skull AP+LAT
X-ray cruris dextra
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X-ray cruris dextra
CT Scan Head
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CT Scan Head
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Working Diagnosis
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Working Diagnosis
Mild Head Injury + Fracture radius ulna dextra
Management
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Management
CT Scan Head Folley catheter
IVFD RL 20 tpm
Antibiotic
Analgesic
H2 blocker
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THANK YOU