17 Sept 2018

S: Patient was admitted to ER with chief complaint wound in her

right foot since 2 months before admission. Patient also can’t
speak and understand command since 3 days. The family said
patient have been fall from her bedroom and look paralized
especially in her right arm and foot. No experience of fever.
Bowel and urinary no abnormality.
Patient had history of DM and never take medicine.
GCS :E4M4Vafasia
BP : 122/92
HR : 85x/minutes
RR : 22X/minutes
T : 36,9⁰C

Physical examination:
CA -/- SI -/-
SNV +/+ RH-/- wh -/-
BJ reg (+) murmur (-) gallop (-)
Normal bowel sound, flat (+)
Oedema -/-/-/- CRT>2S
 Local examination

a/r calcaneus dextra

Inspection: erythematous, necrotic tissue (+), pus (+), blood (-)

size ±6x7 cm
Palpation: painless, palpable hard, warm
Hematology
 Hb : 7,9
 Leukosit : 28300
 Ht : 24%
 Trombosit : 282
 Keton: (-)

Kidney Function Test

 Ur/cr: 24/0,6

Electrolyte
 Na : 136
 K : 3,9
 Cl : 96
 A: Hyperosmolar Hyperglicemic State
Diabetic foot
Susp Non Haemorragic Stroke

P: loading NaCl 0,9% 2000cc/4 hours

Maintenance Nacl 0,9% 20 dpm
Novorapid 3x30 IU
Ceftriaxone 2x2gr
Ranitidin 2x50mg
Ondancentron 2x4mg
DC
NGT
O2 nasal canul 3lpm
 DATE OF ENTRY 11/9/18

Chief complaint : There is swelling under the umbilicus

S:
Mr. R was admitted to Emergency Department due there is
swelling under the umbilicus since 4 days ago with rubor, kalor,
and dolor. Defecation and normal urination.
O:
Compos Mentis
BP : 110/70 mmHg
HR : 90X/minute
RR : 20X/ minute
T : 36,9°C

Physical Examination :
Head: CA-/- SI -/-
Thorax: BSV +/+ Rh -/- Wh -/-
HS reg +/+ murmur -/- gallop -/-
Abdomen : Flat, normal bowel sound, tympanic (+), tenderness (-),
mass (-)
Extremity: Oedem -/- CRT<2
Local examination
a/r umbilikal :
Inspection : There is swelling under the umbilicus
Palpation : Swelling under the umbilicus (± 5cm x 3 cm), palpable
warm and tenderness
 Hematology
 Hb : 13,5
 Leukocyte : 20.500
 Ht : 39%
 Trombocyte : 323..000
A: Umbilical Abscess

P:
- IVFD RL 20 tpm
- Inj Ceftriaxone 1x2 gr
- Inj Ketorolac 3x1
- Paracetamol 3x1
- Operation Schedule : 12/9/2018
 DATE OF ENTRY 11/9/18

 Chief complaint : there is a wound on the left knee that feels

painful and difficult to walk

 S:
Mr. K was admitted to Emergency Department due there is a
wound on the left knee since 1 week ago, that feels painful and
difficult to walk. Patiens also complain of fever.
O:
Compos Mentis
BP : 130/80 mmHg
HR : 72X/minute
RR : 20X/ minute
T : 37,5°C

Physical Examination :
Head: CA-/- SI -/-
Thorax: SNV +/+ Rh -/- Wh -/-
BJ reg +/+ murmur -/- gallop -/-
Abdomen : Flat, normal bowel sound, tympanic (+), tenderness (-),
mass (-)
Extremity: Oedem -/- CRT<2
Local examination
a/r patella sinistra :
Inspection : there is a wound on the left knee (±3cmx3cm),
swelling (+), erythematous (+), krusta (+) and abscess (+)
Palpation : feel warm, tenderness (+),
 Hematology
 Hb : 12,5
 Leukocyte : 20.200
 Ht : 35%
 Trombocyte : 292.000

 Random Blood Sugar : 126

 A:
-Abscess Patella
-Hypertension gr I

 P:
- IVFD RL 20 tpm
- Inj Ceftriaxone 1x2gr
- Inj Ketorolac 3x1
- Operatin Schedule : 12/9/2018
 DATE OF ENTRY 11/9/18

Chief complaint : there is a wound on the left foot smelling, pus

and pain.

S:
there is a wound on the left foot smelling, pus and pain since 2
weeks ago.
History: DM (+); HT (-)
A history of amputation in the left big toe and left foot heel in
January and June at Sari Asih Ar-Rahmah Hospital.
O:
Compos Mentis
BP : 120/70 mmHg
HR : 92X/minute
RR : 20X/ minute
T : 36,4°C

Physical Examination :
Head: CA-/- SI -/-
Thorax: SNV +/+ Rh -/- Wh -/-
BJ reg +/+ murmur -/- gallop -/-
Abdomen : Flat, normal bowel sound, tympanic (+), tenderness (-),
mass (-)
Extremity: Oedem -/- CRT<2
Local examination
a/r Pedis Sinistra :
Look : Discoloration (+), Necrotic tissue (+), Gangrene (+), Tissue
loss (+), Ulkus (+), Pus (+), Bone (-), Blood (-) at pedis sinistra
Feel : Dorsalis pedis artery pulse (-), sensoric (-)
 Hematology
 Hb : 8,1
 Leukocyte : 18.600
 Ht : 23%
 Trombocyte : 407.000

 Random Blood Sugar : 296

 Ur/Cr : 24/0,5
A:
- Diabetes Mellitus type II
- Hyperglikemic
 P:
- IVFD RL 20 tpm
- Inj Ceftriaxone 1x2gr
- Inj Ketorolac 3x1
- Novorapid 2x4 iu
- Operatin Schedule : 12/9/2018
 Name : Farrel
 Age : 11 y.o.
 Date of entry : September 12th
 Chief complaint
 Abdominal pain since 3 days prior admitted to hospital.

 History of presenting complaint

 Pain is felt through the whole abdominal area with a high fever.
Complaints accompanied by decreased appetite and body weight.
Patient experienced diarrhea in 1 day prior but resolved without any
medication. The patient claimed that he could still fart.
 The complaint was felt for the first time.
 History of prolong cough has been denied.
 Consciousness
 Compos mentis

 Vital signs
 BP: -
 HR: 96 beats per minute
 RR: 20 breaths per minute
 T: 38C

 Pain score
 6-7
 General examinations
 Head: normal structure, no visible lesions
 Eye: CA -/- , SI -/-
 Chest: Vesicular +/+ , Rh-/- , Wh -/-
S1-2 normal , gallop - , murmur –
 Abdomen: Flat, muscular defense +, decreased bowel sounds
 Extremity: no visible oedem. Accrals are warm.
 Hb: 12,3 g/dL
 Leukocytes: 7600/uL
 Platelet: 225000/uL

 USG results: chronic cholecystitis, peritonitis suspected.

 Peritonitis suspected

 dd/
 Cholecystitis
 Perforated appendicitis
 Emergency department:
 IVFD RL loading 250cc
 Paracetamol 3x250mg
 Cefotaxime 2x1gr IV

 Ward:
 DKI per 6 hours
 IVFD Kaen 3B  1500cc/day
 Cefotaxime 2x700mg IV
 Sanmol 3x300mg
 Surgery on September 15th
 Name : Ricky
 Age : 24 y.o.
 Date of entry : September 13th
 Chief complaint
 Abdominal pain since 1 day prior admitted to hospital.

 History of presenting complaint

 Pain is felt through the whole abdominal area with a high fever.
Complaints accompanied by nausea and vomitting twice a day. Patient
experienced diarrhea 2 times in 2 days prior. The patient claimed that
he couldn’t eat at all.
 The complaint was felt for the second time.
 The first complaint was followed by surgery.
 History of lung treatment of nine months period has been
acknowledged.
 Consciousness
 Compos mentis

 Vital signs
 BP: 60/40 mmHg
 HR: 100 beats per minute
 RR: 30 breaths per minute
 T: 38,2C

 Pain score
 5-6
 General examinations
 Head: normal structure, no visible lesions
 Eye: CA -/- , SI -/-
 Chest: Vesicular +/+ , Rh-/- , Wh -/-
S1-2 normal , gallop - , murmur –
 Abdomen: Flat, muscular defense +, increased bowel sounds
 Extremity: no visible oedem. Accrals are cold.
 Hb: 12,2 g/dL
 Leukocytes: 4600/uL
 Platelet: 293000/uL
 Random glucose level: 76 mg/dL
 HbsAg: non reactive
 Electrolyte:
 Na: 147 mEq/L
 K: 3,8 mmol/L
 Cl: 108 mEq/L
 Kidney function:
 Ureum: 25mg/dL
 Creatinine: 0,8

 Liver function:
 SGOT: 27
 SGPT: 12
 Albumin: 2,6 g/dL ()

 USG results: Bilateral pleural effusion, ascites and cholecystitis.

 Ileus obstruction suspected

 dd/
 Peritonitis
 Emergency department:
 IVFD RL loading 3000cc + HES 1000cc
 Paracetamol 3x500mg IV
 Inj. Ranitidine 2x50 mg IV
 Inj. Ondancetrone 3x4mg IV
 Ceftriaxone 2x1gr IV
 Ketorolac 1x30mg IV
 NGT
 DC

 Ward:
 ICU
 Ceftriaxone 2x1gr IV
 Vascon 0,4 micro
 Ekstra putih telur 20 butir
 Vipalbumin tab 3x2
 + on September 15th
 DATE OF ENTRY 14/9/18

Main complain: Painful swelling on lump around the anus

S:
Mr. S was a 43 year old works as construction worker was
admitted to emergency Department due to painful swelling on
lump around anus, and it cant be manually reduced. He said that
lump can be spontan reduce and manually reduce in the past 7
years, but patients`ve never been treated before. He also
complaining of rectal bleeding. He noticed there were bright red
blood coating his stool and spots of blood on the toilet paper.
There was no change in bowel habit and no family history of
colonic cancer.
O:
Vital sign:
Compos mentis
BP: 120/80
PR: 90X/minutes
RR: 20X/ minutes
T: 36,8°C

Head: CA-/- SI -/-

Thorax: Vesicular +/+ Rh -/- Wh -/-
Heart sound reg +/+ murmur -/- gallop -/-
Abdomen: Bowel sound (+)
Extremitas: Oedem -/- CRT<2
St. lokalis:
 Inspeksi: Lump around anus, skintag(-) fissure (-) ulcus (-)

 Rectal Touche :
 Anal Sfringter(+)
 Lump cant be manually reduced
 Handschoen : blood (-), feses (-)
 Hematology

 Hb: 12,1
 Leukosit: 6900
 Ht: 39%
 Trombossit:260