MR 1 Juni 2019 Tim C

Emergency Case Report
May 31th- June 1st 2019
Resident On duty:
Oscar Tri Joko
Hendy Buana Vijaya
The C Team :
General Surgery : 1 patient
Digestive Surgery :-
Thorax Cardiovascular Surgery : -
Plastic Surgery : 1 patient
Urology Surgery : 1 patient
Neuro Surgery :-
Pediatric Surgery : 2 patients
Oncology Surgery :-
Orthopaedic : 5 Patients
Total : 8 patients
Patient List
Identity/Ag Admission to
No Diagnose Treatment
e ER
1. Mr. M May, 31th Mild Head Injury + Tretment in ER :
Yusuf/46 2019, Lacerated wound at • Crystalloid
left frontalis due to
YO admission at • Antibiotic
stab wound
02.30 pm • Antitetanus serum
RMK. • Analgesic
1.42.96.58 • H2 blocker
Consult to Neuro surgery :

• Debridement + Primary suture
Patient List
e ER
2. Ch. May, 31th Lacerated Tretment in ER :
Hafiza/5 2019, wound at index • Immunoglobulin
YO/ 20 kg admission at finger of left • Antibiotic
02.45 pm hand • Analgesic
RMK. • H2 blocker
1.42.96.59
Consult to Orthopaedic surgery :
• Debridement + Primary suture
Patient List
e ER
3. Mr. May, 31th Clinical Dx : Tretment in ER :
Suriansya 2019, Colic renal • Crystalloid
Abdominal pain
h/59 YO admission at • Antibiotic
Etiological Dx :
08.00 pm Apendicitis • Analgesic
RMK. perforation • H2 blocker
1.42.96.74 Nephrolithiasis
bilateral
Complication Dx : Consult to Urology surgery :
Moderate Right HN • Hospitalized
Severe Left HN
Acute Kidney Injury • Pro Nephrostomy
Other Dx :
Hypertension Consult to Internist :
• Pro HD CITO
Patient List
e ER
4. Mr. May, 31th Partial obstruction of Tretment in ER :
Asmuri/54 2019, small bowel due to • Crystalloid
Volvulus
YO admission at • Antibiotic
10.00 pm • Analgesic
RMK. • H2 blocker
1.42.96.84
Consult to Digestive surgery :

• Pro Laparotomy exploration
Patient List
e ER
5. Mr. May, 31th Abdominal Tretment in ER :
Haikal/21 2019, pain due to • Crystalloid
YO admission at acute • Antibiotic
11.00 pm apendicitis • H2 blocker
RMK.
1.40.96.86
Consult to Digestive surgery :
• USG
• Apendictomy
Patient List
e ER
6. Mrs. June, 1st Cachexia + Tretment in ER :
Malihani/4 2019, Meningioma gr I • Crystalloid : Dextrose
post chemotherapy
4 YO admission at • Antiemetic
01.00 am Karnofsky : 50-60 • H2 blocker
RMK.
1.42.90.04 Consult to Neurosurgery surgery :
• Hospitalized
• Improvement general condition
Patient List
e ER
7. Mr. June, 1th Closed fracture of Tretment in ER :
Marhani / 2019, right glenoid ideberg • Crystalloid
type II
43 YO admission at • Analgesic
01.45 am • H2 blocker
RMK.
1.42.96.94 Consult to Orthopaedic surgery :
• Imobilization with arm sling
• Conservative treatment
Patient List
e ER
8. Ch. Yofa /7 June, 1st Close fracture Tretment in ER :
YO/ 45 kg 2019, os nasal • Crystalloid
admission at • Analgesic
RMK. 01.45 am • H2 blocker
1.42.96.93
Consult to Plastic surgery :
• Hospitalized
• Pro ORIF elective
Patient List
e ER
9. Mrs. June, 1st Mild Head Injury + Le Tretment in ER :
Rosmiah / 2019, fort I + Close fracture • Crystalloid
nasal + Elevated
64 YO admission at • Antiemetic
transaminase enzym
02.00 am • Analgesic
RMK. • H2 blocker
1.42.96.91
Consult to Neurosurgery surgery :
• Conservative
Consult to Plastic surgery :

• Pro ORIF elective
1. Mr. M Yusuf/46 YO/ MR 1.42.96.58
May 31st 2019 at 02:30 pm
Chief Complain : pain at head

History taking :
Patient complained pain in head since 1 hour before admission after hit by sword. There was blood come out from the
wound.
History decrease of consciousness (-), fainting (-), vomiting (-), blur vision (-). Patient claim there was no history blood
come out from the both ear and nose (-)
The patient taken to the Ulin Hospital immediately for treatment.
History of Past Illness : (-)

History of Family Illness : (-)
Primary Survey
Airway :
• Snoring (-) gurgling (-), without C-Spine control
Breathing :
• Symmetrical movement, RR : 18x/minute (regular), symmetrical vesicular breath sound
(+/+), sonor/sonor (+/+). SpO2 : 98% without O2
Circulation :
• HR : 92x/minute (regular, strong pulse), BP : 120/70 mmHg, warm extremities. Active
bleeding (+)
Disability :
• GCS E4V5M6, pupil equal 2 mm/2 mm, light reflex (+/+), lateralization (-/-)
Secondary Survey
• Allergy : (-)
• Medication : (-)
• Past Illness : (-)
• Last Meal : 10.00 am
• Environment : Hit by Sword at Pekapuran, Banjarmasin
Physical Examination
Head & Neck
• Anemic conjunctiva (-/-), icteric sclera (-/-), Oedema palpebra (-/-), light
reflex(+/+), pupil equal (2mm/2mm)
Chest
• I : Symmetric respiratory movement, no retraction, wound (-/-), lesion (-/-)
• P : Symmetric VF
• P : Sonor at all lung fields, tenderness (-/-)
• A : symmetric VBS, rhonchi (-/-), wheezing (-/-)
Abdomen
• I : Distension (-)
• A : Bowel sound (+) normal 6-8x/min
• P : mass palpable (-), liver / spleen not palpable, tenderness (sde)
• P : Tymphanic
Extrimities
• Warm extremity (+/+), edema (-/-), paralysis (-/-), right lateralization
Localize State at frontalis
Inspection :
Open wound (+), bone exposure (+) active
bleeding (+), active bleeding (+)
Palpation :
Tenderness (+), crepitation (-)
Clinical picture
Skull X Ray ULIN General
Hospital (May, 31 2019)
Laboratory Finding 15/5/2019
Examination Result Reference Value

Hemoglobin 12,8 12,00-16,00 g/dl
Leukosit 12,4 4,0-10,5 ribu/ul
Eritrosit 4,17 3,90-5,50 juta/ul
Hematokrit 37,7 37,00-47,00 vol%
Trombosit 263 150-450 ribu/ul
RDW-CV 13,3 11,5-14,7 %
MCV 90,4 80,0-97,0 f
MCH 30,7 27,0-32,0 pg
MCHC 34,0 32,0- 38,0 %
Gran # 10,87 2,50-7,00 ribu/ul
Limfosit # 1,01 1,25-4,0 ribu/ul
Gran % 87,8 50,0 – 81,0 %
Limfosit % 8,2 20,0-40,0 %
Examination Result Reference value
Natrium 137 135-146 mmol/l
Kalium 4,2 3,4-5,4 mmol/l
Chlorida 101 95-100 mmol/l
PT 10,5 9.9-13,5 detik
APTT 21,9 22,2-37,0 detik
Ureum 39 0-50 mg/dL
Creatinin 1,24 0,72-1,25 Mg/dL
SGOT 25 5-34 U/L
SGPT 36 0-55 U/L
Working Diagnosis
Mild Head Injury + Lacerated wound at left frontalis due to

stab wound
Management
Treatment in ER: Consult to
• O2 10-15 lpm NRM Neurosurgery :
• IVFD RL 2000cc/24 hours Pro debridement
• Inj. Ceftriaxone 2x1gr
• Inj. ATS 1500 IU
• Inj. Ketorolac 3x30mg
• Inj. Ranitidin 2x50mg
2. Ch. Hafiza /5 YO/ 20 kg/ MR 1.42.96.59
May 31st 2019 at 02:45 pm
Chief Complain : pain at right index finger

History taking :
Patients came to ER with complaints of pain at right index finger on left hand after her finger jammed in the door. It
happened an hours before admission. She scare to move her finger because pain.
There is no history of decrease of consciousness, no fainting (-), no vomiting (-), no blur vision (-).
The patient was taken to the Ulin Hospital for treatment immediately.

Primary Survey
• Airway :
• Speak (+) clearly, Snoring (-) gurgling (-), without C-Spine control
• Breathing :
• Symmetrical movement, RR : 20x/minute (regular), vesicular breath sound (+/+),
sonor/sonor. SpO2 : 98% without O2
• Circulation :
• HR : 101x/minute (regular, strong pulse), CRT <2”, warm extremities. Active bleeding
(-).
• Disability :
• GCS E4V5M6, pupil equal 2 mm/2 mm, light reflex (+/+), lateralization (-)
Secondary Survey
• Allergy : (-)
• Environment : Pemangkih Laut, Banjarmasin
Head & Neck
Chest
Abdomen
• I : Lesion (-), distension (-) massa (-)
• A : Bowel sound (+) normal 6-8x/min
• P : mass palpable (-), liver / spleen not palpable, tenderness (-)
• P : Tymphanic
Extrimities
• Warm extremity (+/+), edema (-/-), paralysis (-/-), lateralization (-/-)
Localize State at left hand
Look :
Open wound (+), bone and tendon exposure
(+) at digiti I, deformity (+), active bleeding
(+), amputate (+)
Feel :
Tenderness (+), sensibility (-), CRT difficult to
evaluated
Move :
ROM digiti I (+)
Active : flexion/extension (+/+)
Clinical picture
Left Hand X Ray
ULIN General Hospital
(May, 31 2019)
Working Diagnosis
Lacerated wound at index finger of left hand

Management
Treatment in ER: Consult to Orthopaedic :
• O2 10-15 lpm NRM PRO Repair stump
• IVFD D5 ½ NS 1500cc/24 hours
• Inj. Ceftriaxnone 2x500mg
• Inj. Metamizol 3x200mg
3. Mr. Suriansyah/59 YO/ MR 1.42.96.74
May 31st 2019 at 20:00 pm
Chief Complaint: abdominal pain

History taking :
Patient comes to the hospital with abdominal pain since 1 week ago. The pain appears slowly
and getting worse. The pain speared to whole abdomen, but dominantly in right side.
Patient also complained about nausea and vomiting, vomiting was more than 3 times with
containing the food. Patient defecated with hard consistency, little amount, no blood.
Patient had history about urinating with reddish color, but there was painful. There were no
passing stone and bloody discharge. The patient claim suddenly patient couldn’t urinate then
performed insertion of catheter.
The patient was taken to the Hospital and treated for five days, patient have the USG test and
the result patient have stones in the right kidney and swollen kidney. Then patient refered to
The Ulin General hHspital for further examination.
Vital Sign
• GCS :E4V5M6
• BP : 150/80 mmHg
• HR : 85 bpm, regular and strong
• RR : 20 bpm, without O2 supplement
• Tax : 36,6 C
• NGT : Green color(+)
• Head & Neck
• Anemic conjunctiva (-/-), icteric sclera (-/-), Oedema palpebra (-/-), light reflex(+/+), pupil equal
(2mm/2mm)
• Chest
• Abdomen
• I : Distension (+), darm contour (-), darm steifung (-), scar (-)
• A : Bowel sound (+) 2-4x/min
• P : mass palpable (-), liver / spleen not palpable, tenderness (-), defence muscular (-)
• P : Tymphanic
• Extrimities
• Warm extremity (+/+), edema (-/-), paralysis (-/-/-/-), right lateralization
Urological state
CVA Penis
• I : hematoma (-/-), hyperemic (-/-)
• I : bloody discharge (-),
• P : tenderness (-/-), kidney knock
pain (+/-) hematoma (-), hyperemic
(-)
Flank
• I : hematoma (-/-), hyperemic (-/-) • P : tenderness (-), mass (-)
• P : tenderness (+/-) Scrotum
Suprapubic • I : hematoma (-/-),
• I : hematoma (-), hyperemic (-),
scar (-)
hyperemic (-/-)
• P : tenderness (-) • P : tenderness (-/-)
Digital Rectal Examination
Inspection :
• Hemorrhoid (-), blood (-)
Palpation :
• Spincter ani
• Ampulla recti collaps
• Smooth mucosa
• Mass (-)
• Tenderness (-)
• Handscoon : faces (+), blood (-)
Clinical picture
Chest X Ray
ULIN General
Hospital ( )
BOF X Ray
Pelaihari General
Hospital ( )
USG abdomen
Pelaihari Hospital ( )

RDW-CV 13,5 11,5-14,7 %
MCV 76,9 80,0-97,0 f
MCH 26,8 27,0-32,0 pg
MCHC 33,8 32,0- 38,0 %
Gran # 1,6 2,50-7,00 ribu/ul
Gran % 77,1 50,0 – 81,0 %
Limfosit % 10,8 20,0-40,0 %
Natrium 135-146 mmol/l
Kalium 3,4-5,4 mmol/l
Chlorida 95-100 mmol/l
RBG 104 80-200 mg/dl
PT - 9.9-13,5 detik
APTT - 22,2-37,0 detik
Ureum 177 0-50 mg/dL
SGOT 28 5-34 U/L
SGPT 22 0-55 U/L
Working Diagnosis
Clinical Dx :
Colic renal
Abdominal pain
Etiological Dx :
Apendicitis perforation
Nephrolithiasis bilateral
Complication Dx :
Moderate Right HN
Severe Left HN
Other Dx :
Hypertension
Management
Treatment in ER: Consult to Urology :
• O2 10-15 lpm NRM Pro Nephrostomy
• IVFD NS 1500cc/24 hours
• Inj. Ceftriaxone 2x1gr Consult to Digestive
surgery :
• Inj. Metamizol 3x1gr
No treatment
• Inj. Omeprazol 2x40mg
Consult to Internist :
Pro HD CITO
4. Mr. Asmuri/54 YO/ MR 1.42.96.84
May 31st 2019 at 10:00 pm
Chief Complaint: abdominal pain

History taking :
Patient comes to the hospital with abdominal pain since 3 days before admission. The pain
appears slowly and getting worse. The pain speared to whole abdomen. History of epigastric pain
firstly (-)
Patient also complained about nausea and vomiting, vomiting was more than 3 times with
containing the food. Patient defecated with hard consistency, little amount, no blood.
Patient had history about urinating with reddish color, but there was painful. There were no
passing stone and bloody discharge. The patient claim suddenly patient couldn’t urinate then
performed insertion of catheter.
The patient was taken to the Amuntai Hospital and treated for three days, patient have the
abdominal x-ray performed. Then patient refered to The Ulin General Hospital for further
examination.
Vital Sign
• GCS :E4V5M6
• BP : 100/60 mmHg
• HR : 65 bpm, regular
• RR : 20 bpm, SpO2 : 97% without O2
• Tax : 36,6 C
• VAS : 3-4
• Head & Neck
• Anemic conjunctiva (-/-), icteric sclera (-/-), NGT (+) : greenish blac 100cc
•Chest
• Abdomen
• I : Distension (+), darm contour (-)
• A : Bowel sound (+) normal 4x/min, metallic sound (-)
• P : mass palpable (-), liver / spleen not palpable, tenderness (<) in whole abdomen,
• Defence muscular (-)
• P : Tymphanic
• Extrimities
• Warm extremity (+/+), edema (-/-), paralysis (-/-)
Inspection :
Palpation :
• Spincter ani
• Smooth mucosa
• Mass (-)
• Tenderness (-)
Clinical picture
Chest X Ray
ULIN General
Hospital ( )
Abdomen 3 position X Ray
Amuntai Hospital ( )

Eritrosit 4,,57 3,90-5,50 juta/ul
RDW-CV 13,5 11,5-14,7 %
MCV 80,1 80,0-97,0 f
MCH 25,4 27,0-32,0 pg
MCHC 31,7 32,0- 38,0 %
Gran % 65,9 50,0 – 81,0 %
Limfosit % 25,0 20,0-40,0 %
Gran # 3,3 2,50-7,00 ribu/ul
PT 11,0 9.9-13,5 detik
APTT 22,7 22,2-37,0 detik
Ureum 39 0-50 mg/dL
SGOT 16 5-34 U/L
SGPT 9 0-55 U/L
RBG 90 80-200mg/dl
Working Diagnosis
Partial obstruction of small bowel due to Volvulus

Management
• IVFD NS 20 tpm PRO VP Shunt CITO
• IVFD Manitol 2x250 mg
• Inj Tranexamat acid 4 x 500 mg
• Inj Ranitidin 2 x 1 amp
• Inj Ketorolac 3 x 30 mg
• Drip Nicardipin 5-15 tpm
• Program manitol 6x125 cc
• PO. Candesartan1 x 1 tab
Durante Op
5. Mr. Haikal/21 YO/ MR 1.42.96.86
May 31st 2019 at 11:00 pm
Chief Complaint: Pain in right lower abdoment

History taking :
Patient had complained right lower abdominal pain since 5 day before admission. The
pain felt continuously and it felt like being stabbed. History about pain was at his
epigastrium at first (+). He also complained nausea (+), but no vomiting (-) and patient
had loss of appetite and he only ate a little food.
Patient last defecate was approximately 2 days ago, the stool was yellow and soft
consistency (+), no blood (-).
Patient urinate was yellowish in color and feels warm. Patient denies about disuria (-),
increasing of frequency (-), feeling urgency (-), waist pain (-).
History of trauma (-)
Vital Sign
• GCS :E4V5M6
• BP : 120/80 mmHg
• RR : 18 bpm, SpO2 : 99% without O2 lpm
• Tax : 39 C
• VAS : 2-3
Head & Neck
• Anemic conjunctiva (-/-), icteric sclera (-/-), light reflex(+/+)
Chest
Abdomen
• I : Distension (-)
• A : Bowel sound (+) normal 4x/min
• P : mass palpable (-), liver / spleen not palpable, tenderness (+) Mc burney, psoas sign (+), defence
muscular (-)
• P : Tymphanic
Extrimities
• Warm extremity (+/+), edema (-/-), paralysis (-/-), right lateralization
Inspection :
Palpation :
• Spincter ani
• Smooth mucosa
• Mass (-)
• Tenderness (-)
Clinical picture
Chest X Ray
ULIN General
Hospital ( )

RDW-CV 14,2 11,5-14,7 %
MCV 86,1 80,0-97,0 f
MCH 28,6 27,0-32,0 pg
MCHC 33,3 32,0- 38,0 %
Gran % 73,8 50,0 – 81,0 %
Limfosit % 14,7 20,0-40,0 %
Gran # 13,00 2,50-7,00 ribu/ul
PT 10,5 9.9-13,5 detik
APTT 28,9 22,2-37,0 detik
Ureum 13 0-50 mg/dL
SGOT 25 5-34 U/L
SGPT 33 0-55 U/L
Working Diagnosis
Abdominal pain due to acute appendicitis

Management
Treatment in ER: Consult to Digestive
• IVFD RL 2000cc/24 hours surgery:
• Inj Ceftriaxone 2x1gr USG abdoment
6. Mrs. Malihani /44 YO/ MR 1.42.90.04
June 1st 2019 at 01:00 am
Chief Complain :
History taking :
Patients came to ER with complaints of pain on right foot after traffic accident an hours before admission. She rides a
bicycle, when she turns to the right, suddenly he was beaten by the car from the other side. She falls and her right leg
was hit by a truck. Her right leg is painful to the touch and pain increased if foot try to be moved, but over time it feels
like a tingling sensation. There is no history of bumped chest or large wound in other areas of the body.
History of fainting (-), vomiting (-), blurr vision (-).
The patient is admitted to the Ulin Hospital for treatment.

Vital Sign
• GCS :E2V2M5
• BP : 184/91 mmHg
• RR : 18 bpm, SpO2 : 99% via NRM O2 lpm
• Tax : 36,6 C
• VAS :
Head & Neck
Chest
Abdomen
• P : Tymphanic
Extrimities
Neurological state
• GCS= E2V2M5
• consciousness = Stupor
• Pupil isokor (+/+) 2mm/2mm
• light reflex (+/+)
• Lateralization (+) right
Clinical picture
CT Scan in ULIN
Hospital March-
2019
CT Scan in ULIN
Hospital March-
2019
PA

RDW-CV 14,6 11,5-14,7 %
MCV 89,0 80,0-97,0 f
MCH 29,1 27,0-32,0 pg
MCHC 32,7 32,0- 38,0 %
Gran % 81,1 50,0 – 81,0 %
Limfosit % 11,1 20,0-40,0 %
Gran # 13,90 2,50-7,00 ribu/ul
PT 10,5 9.9-13,5 detik
APTT 21,9 22,2-37,0 detik
Ureum 39 0-50 mg/dL
SGOT 25 5-34 U/L
SGPT 36 0-55 U/L
Working Diagnosis
Cachexia + Meningioma fr I post chemotherapy
Karnofsky : 50-60
Management
• O2 2 lpm Neurosurgery :
• IVFD NS D5% 2000cc/24 hours PRO VP Shunt CITO
7. Mr. Marhani /43 YO/ MR 1.42.96.94
June 1st 2019 at 01:45 pm
Chief Complain : pain at right shoulder

History taking :
Patients came to ER with complaints of pain on right foot after traffic accident an hours before admission. She rides a
bicycle, when she turns to the right, suddenly he was beaten by the car from the other side. He falls and her right
shoulder was hit the street. Patient claim right shoulder is painful to the touch and pain increased if shoulder try to be
moved, but over time it feels like a tingling sensation. There is no history of bumped chest or large wound in other areas
of the body.
History of fainting (-), vomiting (-), blurr vision (-).
The patient is admitted to the Ulin Hospital for treatment.

Primary Survey
• Airway :
• Breathing :
• Symmetrical movement, RR : 19x/minute (regular), vesicular breath sound at (+/+),
sonor percussion at whole region. SpO2 : 98% without O2
• Circulation :
bleeding (-).
• Disability :
Secondary Survey
• Allergy : (-)
• Environment : Binuang, Banjarmasin
Head & Neck
Chest
Abdomen
• P : Tymphanic
Extrimities
Localize State at right shoulder
Look :
Deformity (-), wound (-), deformity
(+), active bleeding (-).
Feel :
Tenderness (+), sensibility (-), CRT
<2”, Sensibility (-)
Move :
ROM adduction/abduction limited due
to pain
Clinical picture
Chest X Ray
ULIN General
Hospital ( )

Hemoglobin 12,00-16,00 g/dl
Leukosit 4,0-10,5 ribu/ul
Eritrosit 3,90-5,50 juta/ul
Hematokrit 37,00-47,00 vol%
Trombosit 150-450 ribu/ul
RDW-CV 11,5-14,7 %
MCV 80,0-97,0 f
MCH 27,0-32,0 pg
MCHC 32,0- 38,0 %
Gran % 50,0 – 81,0 %
Limfosit % 20,0-40,0 %
Gran # 2,50-7,00 ribu/ul
Limfosit # 1,25-4,0 ribu/ul
PT 10,5 9.9-13,5 detik
APTT 21,9 22,2-37,0 detik
Ureum 39 0-50 mg/dL
SGOT 25 5-34 U/L
SGPT 36 0-55 U/L
Working Diagnosis
Closed fracture of right glenoid ideberg type II

Management
• IVFD NS 20 tpm PRO VP Shunt CITO
• IVFD Manitol 2x250 mg
• Inj Tranexamat acid 4 x 500 mg
• Inj Ketorolac 3 x 30 mg
• Drip Nicardipin 5-15 tpm
• Program manitol 6x125 cc
• PO. Candesartan1 x 1 tab
8. Ch. Yofa/7 YO/ 45kg/ MR 1.42.96.93
Chief Complaint: Pain in the nose

History taking :
Patient brought by his family with complained pain in the nose since 6 hours before
admission after traffic accident. Patient use motor cycle, the motor cycle fell down
because avoid the hole in the street.
There were no history decrease of consciousness (-) and seizure, but patient had no
vomiting (-) .
According her family, blood come out from nose, but was stop.
Patient taken to Rantau Hospital immediately for first handling then patient refered to
Ulin Hospital for further treatment
Primary Survey
• Airway :
• Breathing :
sonor percussion at whole region. SpO2 : 99% without O2
• Circulation :
• HR : 98x/minute (regular, strong pulse), warm extremities (+/+), CRT < 2”
• Active bleeding (-).
• Disability :
Secondary Survey
• Allergy : (-)
• Last Meal : 07.00 pm
• Environment : Rantau, Banjarmasin
• Head & Neck
(2mm/2mm)
• Chest
• Abdomen
• P : Tymphanic
• Extrimities
Maxillofacial state
a/r Frontalis a/r Maxillaris dextra et sinistra
• I : deformity (-), swelling (-), wound (-) bleeding • I : deformity (-), swelling (-), wound (-) bleeding
(-) (-)
• P : tenderness (-), crepitation (-) • P : tenderness (+/+), crepitation (+/+), floating
maxilla (+/+)
a/r Rima Orbita dextra et sinistra
a/r Mandibula
• I : deformity (-/-), swelling (+/-), wound (-/-),
palpebra hematom (-/-) • I : deformity (-), swelling (-), wound (-) bleeding
(-)
• P : tenderness (+/-), crepitation (-/-)
• P : tenderness(-), crepitation (-), unstable (-)
a/r Nasalis
a/r Labia Oris Superior et Inferior
• I : deformity (+), swelling (-), wound (+) size
2cmx0,5cm sutured, bleeding (+) flattening (+) • I: Swelling (-), wound (+) at superior size
1x0,5cm sutured, bleeding (-)
• P : tenderness (+), crepitation (+)
• P: Tenderness (-)
a/r Zygoma dextra et sinistra
a/r Intra-Oral
• I : deformity (-/-), swelling (-/-), wound (-/-)
• I : Maloclusion (+), wound (-), bleeding (-)
• P : tenderness (-/-), creapitation (-/-)
• P : Tenderness (-)
Clinical picture
Skull X Ray
ULIN General
Hospital (June,
1 2019)
Thorax X Ray
ULIN General
Hospital (June,
1 2019)

RDW-CV 12,7 11,5-14,7 %
MCV 91,6 80,0-97,0 f
MCH 29,7 27,0-32,0 pg
MCHC 32,5 32,0- 38,0 %
Gran % 88,5 50,0 – 81,0 %
Limfosit % 7,4 20,0-40,0 %
Gran # 9,90 2,50-7,00 ribu/ul
PT 11,9 9.9-13,5 detik
APTT 25,9 22,2-37,0 detik
Ureum 56 0-50 mg/dL
SGOT 185 5-34 U/L
SGPT 132 0-55 U/L
RBG 414 80-200mg/dl11,9
Working Diagnosis
Close fracture nasal

Management
Treatment in ER: Consult to Plastic
• O2 10-15 lpm NRM surgery:
• IVFD NS 20 tpm Pro ORIF electively
9. Mrs. Rosmiah/64 YO/ MR 1.42.96.91
Chief Complaint: Pain in the chick

History taking :
Patient brought by his family with complained pain in the chick since 6 hours before
admission after traffic accident. Patient hit by motor cycle during she walk.
There were no history decrease of consciousness (-) and seizure, but patient had
vomiting > 2 times that containing blood.
According her family, blood come out from nose continuously hence it make patient
difficult to breath.
Patient taken to Mansyur Hospital immediately for first handling then patient refered to
Ulin Hospital for further treatment
Primary Survey
• Airway :
• Breathing :
sonor percussion at whole region. SpO2 : 95% without O2  O2 2 lpm  98%
• Circulation :
bleeding (-).
• Disability :
Secondary Survey
• Allergy : (-)
• Past Illness : (+) DM type 2
• Last Meal : 07.00 pm
• Environment : Banjarbaru, Banjarmasin
• Head & Neck
(2mm/2mm)
• Chest
• Abdomen
• P : Tymphanic
• Extrimities
Maxillofacial state
a/r Frontalis a/r Maxillaris dextra et sinistra
• I : deformity (-), swelling (-), wound (-) bleeding • I : deformity (-), swelling (-), wound (-) bleeding
(-) (-)
• P : tenderness (-), crepitation (-) • P : tenderness (+/+), crepitation (+/+), floating
maxilla (+/+)
a/r Rima Orbita dextra et sinistra
• I : deformity (-/-), swelling (+/-), wound (-/-),
palpebra hematom (-/-) a/r Mandibula
• P : tenderness (+/-), crepitation (-/-) • I : deformity (-), swelling (-), wound (-) bleeding
(-)
a/r Nasalis
• P : tenderness(-), crepitation (-), unstable (-)
• I : deformity (+), swelling (-), wound (+) size
2cmx0,5cm sutured, bleeding (+) flattening (+)
• P : tenderness (+), crepitation (+) a/r Labia Oris Superior et Inferior
a/r Zygoma dextra et sinistra • I: Swelling (-), wound (-), bleeding (-)
• I : deformity (-/-), swelling (-/-), wound (-/-) • P: Tenderness (-)
• P : tenderness (-/-), creapitation (-/-)
Clinical picture
Chest X Ray
ULIN General
Hospital ( )
Skull X-ray AP/Lat
Banjarbaru Hospital
CT Scan in
ULIN
Hospital 1-6-
2019

RDW-CV 12,7 11,5-14,7 %
MCV 91,6 80,0-97,0 f
MCH 29,7 27,0-32,0 pg
MCHC 32,5 32,0- 38,0 %
Gran % 88,5 50,0 – 81,0 %
Limfosit % 7,4 20,0-40,0 %
Gran # 9,90 2,50-7,00 ribu/ul
PT 11,9 9.9-13,5 detik
APTT 25,9 22,2-37,0 detik
Ureum 56 0-50 mg/dL
SGOT 185 5-34 U/L
SGPT 132 0-55 U/L
RBG 414 80-200mg/dl11,9
Working Diagnosis
Mild Head Injury + Le fort I + Close fracture nasal + Elevated

transaminase enzym
Management
Treatment in ER: Consult to Plastic
• O2 10-15 lpm NRM surgery:
• IVFD NS 20 tpm Pro ORIF electively

MR 1 Juni 2019 Tim C

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Emergency Case Report

May 31th- June 1st 2019

Thorax Cardiovascular Surgery : -

Plastic Surgery : 1 patient

Urology Surgery : 1 patient

Pediatric Surgery : 2 patients

Consult to Neuro surgery :

Consult to Digestive surgery :

Consult to Plastic surgery :

Chief Complain : pain at head

History of Past Illness : (-)

Examination Result Reference Value

Mild Head Injury + Lacerated wound at left frontalis due to

Chief Complain : pain at right index finger

History of Past Illness : (-)

Lacerated wound at index finger of left hand

Chief Complaint: abdominal pain

Examination Result Reference Value

Chief Complaint: abdominal pain

Examination Result Reference Value

Partial obstruction of small bowel due to Volvulus

Chief Complaint: Pain in right lower abdoment

Examination Result Reference Value

Abdominal pain due to acute appendicitis

History of Past Illness : (-)

Examination Result Reference Value

Cachexia + Meningioma fr I post chemotherapy

Chief Complain : pain at right shoulder

History of Past Illness : (-)

Examination Result Reference Value

Closed fracture of right glenoid ideberg type II

Chief Complaint: Pain in the nose

Examination Result Reference Value

Close fracture nasal

Chief Complaint: Pain in the chick

Examination Result Reference Value

Mild Head Injury + Le fort I + Close fracture nasal + Elevated

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