Duty Report ER

28 April 2016
(Afternoon Shift)
dr Putri Maulina
dr Alvin K

Rawat Inap

Rawat Jalan

Total

Surgery

Non Surgery

Ob-Gyn

Pediatric

Total

10

Outpatient
No Name

Age

Diagnosis

G (F)

12

Acute Tonsilopharyngitis

S S (F)

28

Urinary Tract Infection + Renal Colic

Suggestive of Urolithiasis (PAPS)

A A (M)

38

Multiple Vulnus Excoriatum

M (F)

32

Susp. Pneumonia dd/ TB (PAPS)

D P A (M)

21

Vulnus Laceratum 0,2 x 0,3 x 1 cm on

the regio Femoral Dextra

A P (F)

11

Fever day 4th due to Urinary Tract

Infection

Inpatient
No Nama

Usia

Diagnosa

A (M)

15

Closed Comminutive Fracture of Right

Iliac Wing + Closed Linear Fracture of
Right Femur

M (F)

38

G5P4A0 + Gravida 38-39 weeks + in

Labour Stage I latent Phase + Single
Fetus, Head Precentation, Alive +
Preeclampsia dd/ Hypertension in
Pregnancy

T S (F)

29

G1P0A0 + Gravida 38 weeks + in Labour

Stage I latent Phase + Single Fetus, Head
Precentation, Alive With Progressive High
Myopia (-6.5 D)

R E (F)

25

G4P2A1 + Gravida 32 weeks + Intra

Uterine Fetal Death (Confirmed with USG
by Sp.OG) + Oblique Precentation

A, Male, 15 years
Closed Comminutive Fracture of Right
Iliac Wing + Closed Linear Fracture of
Right Femur

Chief Complain

Referal from RSUD Karimun with History of

Traffic Accident (13 days) , Closed Fx of right
iliac wing and right Femur

History

History of Traffic Accident 13 days before

admittance to ER. Patient was riding a
mototrcycle in average speed and crashed
into a slow moving pick-up truck from the
side. Patients right iliac and feet collided to
the front bumper of the pick-up truck.
patient was not using helmet, seizure (-),
vomiting (-), Loss of consciousness (-),
amnesia (-). Patient was then admitted to
RSUD karimun for 5 days and then moved to
bakti timah hosmpital for 3 days before
readmitted to RSUD karimun for 5 days.
Complete blood Count, X-ray of pelcic, right
femur, and thorax was present.

History of Disease:History of Medication: Ceftriaxone, Ketorolac, Ranitidine. Skin

Traction of Right femur with 10 kg traction weight

Sensorium: Compos
Mentis
VAS: 2

BP 100/70 mmhg
HR 72 x/minute

Temp 36,7 C
RR 20 x/minute
SpO2 98%

Head

Conjunctiva: Anemic -/-, sclera: icteric -/Light Refex +/+, Pupil Size isocor 2/2 mm

Neck

Trachea: Medial, No other Abnormalities

found

Thorax

I: Fusiform-Simetric, Wound (-), Breathing

simetric
P: Pain (-), Crepitation (-)
P: Sonor on both hemithorax, Pain (-)
A: Breathing Sound: vesiculer Right= Left
Additional Sound: -/Heart Sound: S1S2 (+) N Reg, Gallop(-),
Murmur (-)

Abdomen

Falt, Simetric, Peristaltic (+) N , timpanic,

Pain (-), Flexible, Muscular Rigidity (-)

Extremities

Acral : Warm, CRT < 2 s, Edema (-)

Pelvic Area:
L: Deformity (-), Wound (-)
F: Pain (-), Neurovascular Distal: Normal
M: Reduced ROM, Pain with Movement
Lower Right Extremity:
L: Deformity (+) in Femoral, Shortening, Medial
Angulation 10
F: Pain (+), Axis Tapping Pain (+), Axis Traction
Pain (+), Neurovascular Distal: Normal
M: Reduced Rom, Pain with Movement

Workup

Laboratorium Testing
Complete Blood Count (20/4/2016 RSUD
Karimun)
Hb: 11.0 mg/dl
Ht: 33 g%
Leukosit: 8.610/ uL
Trombosit: 214.000/ uL

Radiologic

Diagnosis

Closed Comminutive Fracture of Right Iliac

Wing + Closed Linear Fracture of Right
Femur

Treatment
Re-Splinting of Right Lower Extremities
Complete Blood Count, Blood Glucose ad
Random
Co. dr. Jorianto, SpOT
Ketorolac 30 mg IV drips in 100 cc NaCl
0,9%/ 8 hours

RE (F), 25 Years
G4P2A1 + Gravida 32 weeks + Intra
Uterine Fetal Death (Confirmed with
USG by Sp.OG) + Oblique Precentation

S: Referral from dr. Dino, SpOG with G4P2A1 + Gravida

32 weeks + Intra Uterine Fetal Death (Confirmed with
USG, Weight 1,9 kg via USG) + Breech Presentation. Last
fetal movement felt 1 day before, contraction (-), bloody
show (-), amniotic fluid (-), history of fever (-), bleeding
(-), trauma (-), High Blood pressure (-). Routine ANC with
Sp.OG, Last ANC this morning with dr. Dino, SpOG.
Obstetric History: 1st Pregnancy Abortus, 2nd Pregnancy
,Female, Death on delivery, 3rd Pregnancy , Female, 3 y o,
Healthy, Vaginal Birth
History of Disease: History of Medication: -

O: sens: CM BP: 120/70 mmhg HR: 84x/m

RR: 20x/m
T: 37 C
Obstetric Examination
Leopold: TFU 27 cm, HIS(-), FHR:-, Oblique
Presentation (head on maternal left side),
Fetal Movement (-)

Diagnosis

G4P2A1 + Gravida 32 weeks + Intra Uterine

Fetal Death (Confirmed with USG by Sp.OG)
+ Oblique Precentation

Treatment
Co. dr. Wahyudi, SpOG
Check CBC, Blood Type, Blood Glucose
Admittance to VK
Reconfirmation via USG result: Positive IUFD
Prepared for Labour via Induction

TS (F), 29 Years
G1P0A0 + Gravida 38 weeks + in Labour Stage I
latent Phase + Single Fetus, Head Precentation,
Alive With Progressive High Myopia (-6.5 D)

S: Contraction since 3 hours before admittance

to ER, Bloody Show (+), Amnion fluid (-), First
day of last menstruation: 4-8-2015, history of
Hypertension in and before pregnancy (-),
G1P0A0, ANC with dr. Wahyudi, SpOG. Last
ANC in the same day of Admittance, Planned
for elective SC 30/4/2016 because of risk of
Ablatio Retina due to High Progressive Myopia
(-6,5 D). Fever (-).
History of Disease: History of Medication: -

O: sens: CM BP: 110/70 mmhg HR: 80x/m

RR: 20x/m
T: 37 C
Obstetric Examination
Leopold: TFU 32 cm, HIS (+) >2x/10 minutes,
Back on Right Side, FHR: 136x/m, Head
Presentation, Descent into Pelvic (+), WellFlexed (+).
VT: Portio thinning (+), d: 2 cm, bloody show
(+), amniontic sac (+), head: Hodge I

Diagnosis

G1P0A0 + Gravida 38 weeks + in Labour

Stage I latent Phase + Single Fetus, Head
Precentation, Alive With Progressive High
Myopia (-6.5 D)

Treatment
Co. dr. Wahyudi, SpOG
Check CBC, Blood Type, Blood Glucose, HIV
Rapid Test, HbsAg, CT/BT
Admittance to VK
Ketoprofen 200 mg Suppository
Scheduled for SC 28/4/2016

M (F), 38 Years
G5P4A0 + Gravida 38-39 weeks + in Labour Stage I
latent Phase + Single Fetus, Head Precentation,
Alive + Preeclampsia dd/ Hypertension in
Pregnancy

S: Contraction since 2 hours before admittance to ER,

Bloody Show (+), Amnion fluid (-), First day of last
menstruation: 10-8-2015, History of High Blood
Pressure (140/90 mmhg) in this pregnancy, history of
Hypertension before pregnancy (-), G5P4A0, 1 st
Female, 23 y.o. Birth Weight (Patient Forget), Healthy.
2nd Female, 11 y.o, 3400 gr, Healthy. 3rd Female, 10 y.o.,
3300 gr, Healthy, 4th Male, 1,5 y.o., 3200 gr, Healthy.
All childs are of Vaginal Birth. ANC with dr.
Amuransyah, SpOG. Refered to ER by Midwife(RSBP).
Fever (-).
History of Disease: History of Medication: -

O: sens: CM BP: 130/80 mmhg HR: 90x/m

RR: 22x/m
T: 37 C
Obstetric Examination
Leopold: TFU 36 cm, HIS (+) 1x/10 minutes,
Back on Right Side, FHR: 138x/m, Head
Presentation, Descent into Pelvic (+), WellFlexed (+).
VT: Portio thinning (+), d: 1 cm, bloody show
(+), amniontic sac (+), head: Hodge I

Diagnosis

G5P4A0 + Gravida 38-39 weeks + in Labour

Stage I latent Phase + Single Fetus, Head
Precentation, Alive + Preeclampsia dd/
Hypertension in Pregnancy

Treatment
Co. dr. Amuransyah, SpOG
Check CBC, Urine, Blood Type, Blood
Glucose
Admittance to VK

Thank You