Emergency Case Report

4th – 5th February 2019

Resident On Duty
Abdullah Putra Perdana
Arif Handoko

Chief Co-Assistant :
Ghina

The A Team :
Sigit, Steven, Tina, Dian, Agus
General Surgery :-
Digestive Surgery : 1 patient
Thorax Cardiovascular Surgery :-
Plastic Surgery :-
Urology Surgery : 1 patient
Neuro Surgery : 2 patient
Pediatric Surgery :-
Oncology Surgery :-
Orthopaedic :-
Total : 4 patients
 Patient List
No Identity Admission to ER Diagnosis Planning

1. Mr. Yamin/ 27 y.o. February, 4th Clinical diagnosis : Acute Treatment From ER
RM. 1.41.79.52 Scrotal - IVFD RL 20 dpm
2019
- Inj. Antipiretik
07.00 pm Etiological diagnosis : - Inj. Antibiotic
Orchidoepididymitis
- Inj. PPI
Complication diagnosis: - - Laboratory Examination
- Urinalysis
Other diagnosis : - - USG Scrotal

Consult to Urology:
- Hospitalized
 Patient List
No Identity Admission to ER Diagnosis Planning

2. Mrs. Rahmina / 39 February, 4th General weakness + Cachexia + Treatment From ER

y.o. 2019 Adeno Carcinoma Colon + - IVFD Cristalloid :
RM. 1.40.22.54 Lymph node metastasis + Glucose
08.00 pm hyponatremia - Inj. H2 Blocker
- Laboratory Examination
- electrolyte correction
- Planning chemotherapy
- High Protein / High
Calorie Diet

Consult to digestive
surgery:
-Hospitalized
 Patient List
No Identity Admission to ER Diagnosis Planning

3. Mr. Maulana/ 24 y.o February 4th 2019 Mild Head Injury + Alcohol Treatment From ER
at 22.45 Abused - O2
- Head up 30 degrees
- IVFD Cristalloid
- Inj. Analgetic
- Inj. H2 Blocker
- Chest X ray
- Observation 6 hours

Patient out by request

 Patient List
No Identity Admission to ER Diagnosis Planning

4. Mr. Abdullah /35 February 5th 2019 Severe Head Injury + SDH + ICH Treatment From ER
y.o at 03:00 am frontotemporoparietal sinistra + - O2
suspected fracture the base of - Head up 30 degrees
craniaum - IVFD Cristalloid
- IVFD Hyperosmolar
agent
- Inj ATS Prophylactic
- Inj. Analgetic
- Inj. H2 Blocker
- Observation

Co to Neurology Surgery :
Craniotomy Evacuation
 1. Mr. Yamin Saputra /27 years old / RM 1.41.79.52
February 4th 2019 at 07.00 pm
Chief Complain : Pain at right scrotum
History taking :
The patient complained of right scrotum pain since 7 days before admission,
continuous pain (+) , pain accompanied by fever, there is no nausea and vomiting,
1 month ago, the patient had history of sexual intercourse with a prostitutes, 1
week later the patient complained of discharge from the white fluid from the
oeu, accompanied by shivering fever. The testicles begin to swollen and
accompanied by pain. Patient can urinate with normally, history of trauma (-),
Pain when chewing or swallowing food (-/-).

History of family illness: Hypertension (-) DM (-)

History of family illness : No one in his family had the same symptom
Vital Sign

Compos mentis
BP : 130/80 mmHg
RR : 18 x/m
HR : 96 bpm
Tax : 38,3 ◦C
GCS : E4V5M6
SpO2 : 98% without O2 supplementary
 Physical Examination
• Head: Normal
Head/Neck • Eyes : anemic conjunctivae(-/-), icteric sclera(-/-),
• Neck: JVP enhancement(-), lymph enlargement (-)

• I: symmetric respiratory movement, retraction (-)

• P: symmetric VF
Chest • P :sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

•I : distention (-) mass (-)

Abdomen •A : bowel sound (+) normal
•P : tympanic
•P : H/L/M = nopalpable,tenderness(-),muscular rigidity(-)

Extremities • warm (+), edema (-),paralysis (-)

Urology state
• CVA • Genitalia external:
- I : hematome (-) mass (-) -penis : edema (-) haematoma (-)
- P : unpapable mass , tenderness (-) CVA (- -Scrotal :
/-) Testicular examination : right testicular
enlargement (+), induration of the testis (+),
• Flank tenderness (+), erythematous scrotal skin
(+), edematous scrotal skin (+), prehn sign
- I : hematome (-), swelling (-) (+) kremaster sign (+),
- P : unpapable mass tenderness (-)
-Oue: discharge (-)
• Suprapubic
- I : distended (-),
- P : tenderness (-) mass (-)
Digital Rectal Examination
•I : mass (-) hemoroid (-) •Prostat
laceration (-) mass (-) Nodule (-)
•P: palpable prostat
Sphincter ani tonus in firm Consistency
normal limit (+) tenderness (-)
Recti mucous normal Regular surface
Ampula recti normal Sulcus mediana
Tenderness (-) Handscoon : faeces (+), blood
(-)
Clinical Pictures
 USG Scrotal, RS Ulin, February 4th 2019

Conclusion :
• Orchitis dextra and epididymitis dextra
• Varicocele Dextra
• There is no abnormalities in the testis sinistra and epididimis sinistra
• There is no torsio testis dextra and epididymis sinistra
Laboratory Finding, RS Ulin, February 4th 2019
Examination Result Nilai Rujukan
Hemoglobin 13.1 12,00-16,00 g/dl
Leukosit 29.2 4,0-10,5 ribu/ul
Eritrosit 4.18 3,90-5,50 juta/ul
Hematokrit 37.0 37,00-47,00 vol%
Trombosit 406 150-450 ribu/ul
RDW-CV 11.5 11,5-14,7 %
MCV 88.5 81,0-99,0 fl
MCH 31.3 27-31pg
MCHC 35.4 33.0-37.0
Gran% 89.7 50-70%
Limfosit% 1.7 25-40%
MID% 8.5 4.0-11.0%
Gran# 26.22 2.50-7.00 thousand/ul
Limfosit# 0.49 1.25-4.0 thousand/ul
MID# 2.50
Laboratory Finding, RS Ulin, February 4th 2019

Pemeriksaan Hasil Nilai Rujukan

PT 11.3 9,9-13,5 detik
INR 1.05
APTT 21.2 22,2-37,0 detik
GDS 125 <200
SGOT 51 0-46 U/l
SGPT 129 0-45 U/l
Ureum 29 10-50 mg/dl
Creatinin 0.68 0,7-1,4 mg/dl
Natrium 132 135-146 mmol/l
Kalium 3.4 3,4-5,4 mmol/l
Chlorida 95 95-100 mmol/l
 Urinalysis, RS Ulin, February 4th 2019
Pemeriksaan Hasil Rujukan
Warna-kekeruhan Kuning Kuning-Jernih
BJ 1.020 1.005-1.030
Ph 6.0 5.0-6.5
Keton Negaitve Negative
Protein-Albumin Trace Negative
Glucose Negative Negative
Bilirubin Negative Negative
Darah samar Negative Negative
Nitrit Negative Negative
Urobilinogen 0.1 0.1-1.0
Leucosit trace Negative
 Urinalysis, RS Ulin, February 4th 2019

Examination Result Normal value

Leucocyte 2-3 0-3
Erythrocyte 0-1 0-2
Cilinder Negative Negative
Epithel Negative 1+
Bactery negative Negative
Crystal Negative Negative
Other Negative Negative
 Working Diagnosis

Clinical diagnosis : Acute Scrotal

Etiological diagnosis : Orchidoepididymitis

Complication diagnosis: -

Other diagnosis : -
 Management

Treatment From ER Consult to Urology:

• IVFD RL 20 dpm • Hospitalized
• Inj. Paracetamol 3 x 30 mg
• Inj. Ciprofloxacine 2 x 400 mg
• Inj. Doxycycline 2 x 100 mg
• Inj. Omeprazole 1x40 mg
• Laboratory examination
• Urinalysis
• USG Scrotal
 2. Mrs. Rahmina/ 39 years old / RM 1.40.22.54
February 4th 2019 at 08.00 pm

Chief Complain : General weakness

History taking:
the patient complained of weakness since 15 days before
admission, there was no complain about abdominal pain,
nausea vomiting (-), the patient also had a decrease in
appetite since 1 month ago. The patient had history of
exploration and biopsy laparotomy in December 2017 in
Balangan hospital because she has a complaint of lumps on
the right side of the abdomen, the lump initially appeared
since June 2017 and grew bigger, there was no pain in lumps,
nausea and vomiting, patients Experienced 8 kg of weight loss
in the last 6 months, patients worked as farmers.
From the results of the biopsy, malignant cells were found,
and patients were planned for chemotherapy
 Vital sign

Compos Mentis

BP : 100/60 mmHg

HR : 95 bpm, regular and strong

RR : 20 bpm

Tax : 36.7 C

SpO2 : 97% without O2 2 lpm

Physical Examination
• Head : Pale conjunctiva (-|-), light reflex (+|+), Edema
palpebra (-/-), icteric sclera (-|-)
Head • Mouth : Moist mucous membrane
• Neck : Increased level of JVP (-), enlargement of lymph
nodes (-)

• I : symmetrical respiratory movement, retraction (-),

• P : symmetrical VF
Chest • P : sonor at all lung fields
• A : symmetrical VBS , no ronchi, no wheezing
• I : distension (-) abdomen symmetric (+), Scar laparotomy (+)
• A : Bowel sound (-)
• P : timfany at all abdomen region
Abdomen • P : palpable mass (+) at Right quadran, size 17 x 7 cm, mobile
(+) irregular surfe (+) hard consistency (+), tenderness (-)
Muscle Rigidity (-)

Extremities • warm extremities (+/+), edema (-/-) , parese (-/-)

Digital Rectal Examination

Inspection: Palpation:
• Mass (-) • Smooth rectal mucosa
• Blood (-) • Normal spincter anal
• Feces (-) • Tenderness (-)
• Normal ampulla recti
• Mass (-)
• At handscoon, faeces (-), blood (-)
Clinical Pictures
Abdominal X-Ray, February 4th 2019
Laboratory Finding, RS Ulin, February 4th 2019
Examination Result Nilai Rujukan
Hemoglobin 13.7 12,00-16,00 g/dl
Leukosit 8.7 4,0-10,5 ribu/ul
Eritrosit 5.03 3,90-5,50 juta/ul
Hematokrit 40.5 37,00-47,00 vol%
Trombosit 300 150-450 ribu/ul
RDW-CV 16.2 11,5-14,7 %
MCV 80.5 81,0-99,0 fl
MCH 27.2 27-31pg
MCHC 33.8 33.0-37.0
Gran% 83.5 50-70%
Limfosit% 11.8 25-40%
MID% 4.7 4.0-11.0%
Gran# 7.30 2.50-7.00 thousand/ul
Limfosit# 1.00 1.25-4.0 thousand/ul
MID# 0.4
Laboratory Finding, RS Ulin, February 4th 2019

Pemeriksaan Hasil Nilai Rujukan

GDS 66 <200
SGOT 12 0-46 U/l
SGPT 8 0-45 U/l
Ureum 37 10-50 mg/dl
Creatinin 0.14 0,7-1,4 mg/dl
Natrium 126 135-146 mmol/l
Kalium 3.8 3,4-5,4 mmol/l
Chlorida 92 95-100 mmol/l
 Histopatologi, Syifa Clinic, February 4th 2019

P.674.11.18 / November 8th 2018 /dr. Barliana Sp. PA :

Conclusion:
- ascending colon tumor
- resection surgery: moderate differentiated adenocarcinoma
(grade 2) grows to the serous layer
- metastasis on 6 lymphonode from 12 lymphonode found
stage III (pT3pN2Mx), dukes stage C (MAC C2)
 Working Diagnosis

General weakness + Cachexia + Adeno Carcinoma Colon +

Lymph node metastasis + hyponatremia
 Management

Treatmen from ER : Consult to digestive surgery :

- IVFD Nacl 0,9 % 20 dpm Hospitalized
- Inj. Ranitidine 2 x 50 mg
- Laboratory examination
- electrolyte correction
- Planning chemotherapy
- High Protein / High Calorie Diet
 3. Mr. Maulana/ 24 y.o
February 4th 2019 at 22.45

Chief Complain : Decreased of conciousness

History :
• The complaint start after he had an motorcycle accident
about 30 minutes before admission. According to the
patient, he fell from his motorcycle after suddenly hit the
front brake. After that he only lay on the road and then he
woke up at the ulin hospital. Shortness of breath (-),
Hiperventilation (+)
• He also complaint about headache at his right side and
right thigh. Also there is rigidity at both hands. Nausea (-),
Vomitting (-), Fever (-).
• There is no bleeding throught ears, nose, or mouth.
• Before the accident, patient drank 4 slockey of Vodca
 Primary Survey

A • Clear, without C Spine Control

• Symmetrical movement, symmetrical VBS RR : 21

B bpm, SpO2: 97%

• HR: 89 bpm, regular and strong, BP :

C 110/70mmhg, active bleeding (-)

D • GCS E4V5M6 (15), Pupil : equal 3mm/3mm, light reflect

(+/+), Lateralization
A •Seafood

M •-

P •-

L • Rice, around 20.00

E • On the road
 Physical Examination
• VE (+) a/r sphenoid bone dx, Lesion (-) Palpebra
hematoma (-/-) pale conjungtiva (-/-), sclera icteric (-/-)
Head/Neck direct light reflex (+/+), enlargement lymph node (-) pupil
equal (3mm/3mm)

• I : symmetric respiratory movement, retraction(-) wound (-) lesion (-)

• P : symmetric VF
Chest • P : sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

• I : distention (-) wound (-) lesion (-)

• A : normal bowel sound
Abdomen • P : Tympanic
• P : tenderness (-) rebound tenderness (-), muscular
rigidity (-)

• warm (+), edema (-/-), no paralysis, VE (+) patella dx

Extremities lesion (-), lateralization (-)
Clinical Pictures
Working Diagnosis

Mild Head Injury + Alcohol Abused

 Management

Treatment from Emergency Room

• O2 2-3 lpm NC
• Head up 30 degrees
• IVFD RL Loading 500 cc, maintenance 20 dpm
• Inj. Ketorolac 3x30 mg
• Chest X-Ray
• Observation 6 hours

• Patient out by request

 4. Mr. Abdullah /35 y.o
February 5th 2019 at 03:00 am

Chief Complain : Decrease of consciousness

History :
• Decreased consciousness since 2 days before admission
the hospital. The patient fell from a height of 3m when
repairing the ceiling, the patient fell down with the head
hit the floor. After falling the patient is unconscious
immediately. 2x vomiting (+), seizures (-), bleeding from
the ears and nose are unknown.
• Long patients are taken to the puskesmas and then
referred to Tanah Bumbu Hospital. From the Tanah Bumbu
Hospital, the family did not want to be referred to, and
was treated for 2 days, and just wanted to be referred
today to Ulin Hospital.
• History of illness: HT (-) DM (-)
 Primary Survey

A • Clear, with C Spine Control, gurgling (-) snoring (-)

• symmetrical movement, symmetrical VBS RR : 24

B bpm, Whezing (-), Rhonki (-) SpO2: 100% with O2
10 lpm NRM

• HR: 89 bpm, regular and strong, BP :

C 110/80mmhg, active bleeding (-)

D • GCS E1V2M5 (8), Pupil : anequal 2mm/3mm, light

reflect (+/+), Lateralization (-)
A •-
• Analgetic, antibiotic, H2 Blocker,
M Hypearosmolaritic agent

P •-

L • 2 days ago

E • In house(Tanah Bumbu)
 Physical Examination
• Wound (-), Lesion (-) Palpebra hematoma (-/-) pale
conjungtiva (-/-), sclera icteric (-/-) direct light reflex (+/+),
Head/Neck enlargement lymph node (-), BH (-/-), BS (+/-), BO (-/-), BR (-
/-),

• I : symmetric respiratory movement, retraction(-) wound (-) lesion (-)

• P : Crepitasion (-), tenderness (sde)
Chest • P : sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

• I : distention (-) wound (-) lesion (-)

• A : normal bowel sound
Abdomen • P : Tympanic
• P : tenderness (-) rebound tenderness (-), muscular
rigidity (-)

• warm (+), edema (-/-), no paralysis, wound (+) lesion (-),

Extremities lateralization (-)
Clinical Pictures
X-ray
Head CT Scan
Head CT Scan
Laboratory Finding, RS Ulin, February 5th 2019
Examination Result Nilai Rujukan
Hemoglobin 12.4 12,00-16,00 g/dl
Leukosit 9.6 4,0-10,5 ribu/ul
Eritrosit 4.33 3,90-5,50 juta/ul
Hematokrit 36.8 37,00-47,00 vol%
Trombosit 127 150-450 ribu/ul
RDW-CV 12.5 11,5-14,7 %
MCV 85.0 81,0-99,0 fl
MCH 28.6 27-31pg
MCHC 33.7 33.0-37.0
Gran% 76.2 50-70%
Limfosit% 16.3 25-40%
MID% 7.5 4.0-11.0%
Gran# 7.30 2.50-7.00 thousand/ul
Limfosit# 1.60 1.25-4.0 thousand/ul
MID# 0.7
Laboratory Finding, RS Ulin, February 5th 2019

Pemeriksaan Hasil Nilai Rujukan

GDS 128 <200
SGOT 42 0-46 U/l
SGPT 28 0-45 U/l
Ureum 31 10-50 mg/dl
Creatinin 0.40 0,7-1,4 mg/dl
Natrium 140 135-146 mmol/l
Kalium 3.7 3,4-5,4 mmol/l
Chlorida 104 95-100 mmol/l
Working Diagnosis

Severe Head Injury + SDH + ICH

frontotemporoparietal sinistra +
suspected fracture the base of craniaum
 Management

Treatment from Emergency Room Co to Neurology Surgery :

• O2 10 lpm NRM • Craniotomy Evacuation
• Head up 30 degrees
• IVFD NS 2000 / 24 hours
• IVFD Manitol 4x100 cc
• Inj Ceftriaxone 2x1 gr
• Inj Paracetamol 3x1 gr
• Inj Ranitidine 2x50 mg
• Inj ATS Prophylaxis