Emergency Room Morning Report: March 25 26 2018

Emergency Room
Morning Report
March 25th – 26th 2018
Resident on Duty
Dr. Hendy
Chief on duty
Rizka
Coass on Duty:
Elly, Rugayah, Halis, Kevin, Nadia,
Ulfia, Jordan, Dyah
General Surgery :
Digestive Surgery :
Thorax Cardiovascular Surgery : -
Plastic Surgery :-
Urology Surgery : 1 patient
Neuro Surgery :
Pediatric Surgery :
Oncology Surgery : -
Orthopaedic : 1 patient
Total : patients
Patient List
Admission to
No Identity Diagnosis Treatment
ER
1 Child Raffi March 25th open fracture at IVFD RL 20 dpm

Ezra/ 8 yo 2018 at right ulna middle Inj. Ceftriaxone 2x1 gr
09.05 am 3rd oblique Inj. Ketorolac 3x 15 mg
displaced GA Inj. Ranitidin 2x 25 mg
grade I and Inj. Tetagam 1 amp
closed buckle (IM)
fracture at CBC, ureum creatinin,
proximal radius ALT/AST, PT/APTT,
½ middle radius Electrolite status
Ro. Antebrachii (D)
Thorax PA
Debridement at open
wound with NaCl 0.9%
2 lt
Co. orthophaedic
surgery:
Advice:
Patient List
Admission to
No Identity Diagnosis Treatment
ER
2 Mr. Gusti March 25st Clinical diagnosis: Inf. RL+drip tramadol
Kamarul 2018 at 10.00 Right region 1amp 20 dpm
Zaman/ 52 y.o am abdominal pain Inj. Ceftriaxone 2x1gr
Inj. Ranitidine 2x50 mg
Etiology diagnosis:
renal cyst dextra Consult to Urology :
Complication
diagnosis: -
Hypertension
Grade II
Other diagnosis:
Low Extremities
1. Ch. M. Raffi/ 8 yo
Chief Complain:
Pain on the right arm
History taking :
Patient came to ER with pain on his right arm since 1 day ago. The pain came
up after he fell on the field while playing football with his hand supporting his
body. His right arm was bent and hurts, but there wasn’t open wound. His
family brought him to massage, after treatment the bent angle of his arm and
the pain was decreasing. In the morning before admission, the patient fell
again while playing with his sibling, with the same position as the first
accident. After the accident he complained the pain on his arm was worsening
and the bent on his arm increased with open wound that had no active
bleeding, He couldn’t grip his hand. Nausea (-) Vomitting (-) Headache (-)
Seizure (-)
History of Trauma : (-)
History of Family Illness : (-)
Primary Survey
A : Clear, without c-spine control
B : RR 20 x/mnt, wound (-), simetris, vesicular
C : HR 95 x/mnt, wound (-) strong regular
D : GCS 15 E4 V5 M6, pupil equal (3mm/3mm) RC (+/+)
lateralization (-) BH ( -) BS ( -) BO (- ) BR ( -)
Secondary survey
A : (-)
M: (-)
P : (-)
L : 11.30 AM
E : on the field
Vital Sign
HR: 95 bpm
RR: 20 tpm
T: 37oC
SpO2 98% without O2 supply
Physical Examination
• Sclera icteric (-/-), pale conjungtiva (-/-), enlargement lymph
Head node (-)
• I : wound (-), symetric respiratory movement, retraction (-),

bruise (-)
Chest • P : Symmetric vocal fremitus
• P : Sonor at all lung fields
• A : symmetric VBS, rhonchi (-), wheezing (-)
• I : wound (-), distention (-)
• A : Bowel sound (+) normal
Abdomen • P : defance muscular (-) tenderness (-), mass (-) ascites (-)
• P : Tymphani at all region
• warm extremities (+)

• Edema (-)
Extremities • Deformity at regio antebrachii dextra, open wound (+), warm
(+), CRT < 2”
Clinical picture
STATUS LOCALIS
A/r antebracii dextra

L: deformity (+), open wound (+)
F: crepitus wasn’t checked ,
tenderness (+)
M: active ROM (+) limited due to pain
passive ROM (+) limited due to
pain
Laboratory 25/3/ 2018
Working Diagnose
open fracture at right ulna

middle 3rd oblique displaced
GA grade I and closed buckle
fracture at proximal radius
½ middle radius
Management
IVFD RL 20 dpm
Inj. Ceftriaxone 2x1 gr
Inj. Ketorolac 3x 15 mg
Inj. Ranitidin 2x 25 mg
Inj. Tetagam 1 amp (IM)
CBC, ureum creatinin, ALT/AST, PT/APTT, Electrolite
status
Ro. Antebrachii (D)
Thorax PA
Debridement at open wound with NaCl 0.9% 2 lt
Co. orthophaedic surgery:

Advice:
ORIF Plate Screw tomorrow (26/3/18)
2. Mr. Gusti Kamarul
Zaman/ 52 y.o
Chief Complain:
Right region abdominal pain
History taking
Patient came to ER with right region abdominal pain since 5 months ago
intermittently. The pain spread to his whole body. The pain increased if he lay to
right side. Patient had intermittent fever along with the pain. When patient felt
pain, he hard to urinating .His urine is clear, without blood and sandy
appearance.
He had difficulty to defecate since 1992. When he defecate, it was hard to came
out that he need to manually took it out by hand. When the defecation was very
difficult and he strained a lot, he had blood dripping from his anal and it’s very
painful.
2. Mr. Gusti Kamarul
Zaman/ 52 y.o
History of Past illness:

• Patient had spine injury 26 years ago then both of his lower limb got
paralyzed.
• Catheter usage for 4 years after his lower limb paralyze on 1992 and when he
had dental operation 6 months ago.
• Hypertension (-)
History of family illness: There is no same complains with patient

Vital Sign
E4V5M6
BP: 160/100 mmHg
RR: 18 tpm
HR: 98 bpm
T: 36.8oC
SpO2 98% without O2 supply
Physical
Examination• Sclera icteric (-/-), pale conjungtiva (-/-), enlargement lymph
Head node (-)
• I : symetric respiratory movement, retraction (-), bruise (-)

• P : Symmetric vocal fremitus
Chest • P : Sonor at all lung fields
•I : distension (-)
•A : Bowel sound (+) normal
•P : Tymphani at all region
Abdomen •P : defance muscular (-), tenderness (+) a/r left and right
lumbar , mass (-) ascites (-)
Extremities • warm extremities (+)

CLINICAL PICTURE
Flank Area
Urology • Inspection: mass (-/-), hematom (-/-), bruise (-)

• Palpation : mass was not palpaple, tenderness (+/-)
state
CVA
• Inspection: bruise (-/-), hematom (-/-)
• Palpation: mass (-), tenderness (-/-)
• Percusion: CVA tenderness (-/-)
Suprapubic
• Inspection : suprapubic bulge (-), scars (-), hematom (-) mass

(-)
• Palpation : tenderness (-)
Genitalia
• OUE : bloody discharge (-), edem (-), catheter (-)

• Penis : mass (-), hematom (-), tenderness (-)
• Scrotum : hiperemis (-), swelling (-), tenderness (-), testis
normal
Rectal Toucher
I : haemorrhoid (-), laceration (-), mass (-), fistle (-)
P:
- Spincter ani tone : (+) decreased
- Mucosa was not slippery
- Ampulla was not collapse
- Mass (-)
Tenderness (-)
- Prostat :
– Touched, chewy consistence
– Nodule (-)
– Flat surface
– Mediana sulci unflat
– Upper pole easy to touch
– Prostat ±20 g
– Tenderness (-)
– BCR (+) N
- Handscon : Feces (+), blood (+)
Examination Result Normal value
Hematology
Hemoglobin 12.2 14.00-18.00 g/dl
Leucocyte 5.2 4.00-10.5 103 /ul
Eritrocyte 5.11 4.10-6.00 million/ul

LABORATORY
7th March
Hematocrit 36.8 37.0-47.0 Vol%
2018 Thrombocyte 228 150-450 103 /ul
RDW-CV 18.3 12.1-14.00 %
MCV, MCH, MCHC
MCV 72.1 75.0-96.0 fl
MCH 23.8 28.0-32.0 pg
MCHC 33.1 33.0-37.0 %

Diff Count
Gran % 57.5 50.0-70.0 %
Lymphocyte % 32.2 25.0-40.0 %
MID% 10.3 4.0-11.0 %
Gran# 3 2.50-7.00 thousand/ul
Lymphocyte# 1.7 1.25-4.0 thousand/ul

MID# 0.5 thousand/ul
Random Blood 119 <200 mg/dl
Glucose
Hemostasis
PT 9.9 9.9-13.5 second
APTT 26.3 22.2-37 second
Blood Glucose
Kidney Function
Ureum 17 10-50 mg/dL
Creatinin 1.40 0.6-1.2 mg/dL
Uric Acid 7.70 2.4-5.7 Mg/dl
Electrolyte
Natrium 140 135-146 mmol/L
Kalium 3.4 3.5-5.4 mmol/L
Chlorida 105 95-100 mmol/L
Fatty Level
&Cardio
Total Cholesterol 226 150-220 Mg/dl
Liver
Albumin 3.90 3.5-5.5 g/dl
USG ABDOMEN
CT SCAN UROLOGY
Working Diagnose
Clinical : Right abdominal pain

Etiology: Right kidney Cyst
Complication: Hypertension
Other: -
Management
IVFD NS + drip
tramadol 1 amp in 1
kolf NS 20 dpm
Inj Ceftriaxone 2x1 gr
Inj Ranitidin 2x1 amp
Consult to Urology:
2. Tn. Marlin/ 70 years old
Chief Complain: Low back pain

History taking:
A patient complained he felt low back pain since 1 month before admission
then increasing this past 2 weeks. The pain appeared suddenly and
intermittently then spread to stomach. No nausea and vomitting. No complain
of defecation and urination. Sandy urine, pain and burning sensation weren’t
found. Fever was denied.
• History of Past Illness : Heart failure (+)
• History of Family Illness : Heart failure (+) Hypertension (+)
Vital Sign
BP: 130/80 mmHg
RR: 20 tpm
HR: 85 bpm
T: 37oC
SpO2 98% with O2 supply 4 L/m
Physical
Head node (-)

• I : distention (-)
Abdomen • P : defance muscular (-) tenderness (-) upper right quadrant,
mass (-) ascites (-)
• warm extremities (+)

Extremities • Edema (-)
Local Examination
• CVA: hematom (-/-), jejas (-/-) mass (-/-) nyeri ketok ginjal (-
/+)
• Flank Area: hematom (-/-) jejas (-/-) mass (-/-) nyeri tekan
(<</+)
• Suprapubic: hematom (-/-) jejas (-/-) swelling (-) VU teraba
(+) penuh (-) distensi (-) nyeri tekan (-)
• Pubic: hematom (-/-) jejas (-/-) swelling (-) VU teraba (+)
penuh (-) distensi (-) nyeri tekan (-)
• Genitalia : darah (-) Bloody discharge (-) nyeri (-)
• RT : Mass (-) Spincter ani menjepit kuat, ampula recti tidak
collaps, nyeri tekan (-) pembesaran prostat (-) sulcus
median teraba, BCR (+), Handscoon : feses (+) blood (-)
Clinical picture
Laboratory 13/3 2018
Leucocyte 10.8 4.0-10.5 Thousand /ul
Erytrocyte 3.48 4.50-6.00 milion /ul
Trombocyte 312 150-450 Thousand /ul
RDW-CV 14 12.1-14.0 %
MCV 90.4 75.0 – 96.0 fl
MCH 29.8 28.0 – 32.0 pg
MCHC 33.1 33.0 – 37.0 %
Examination Result Normal Value
Gran% 76.2 50.0-70.0 %
Lymphocyte% 13.7 25.0-40.0 %
MID% 10.1 4.0-11.0 %
Gran# 8.2 2.50-7.00 Thousand/ul
Lymphocyte# 1.5 1.25-4.0 Thousand/ul
MID# 1.1 Thousand/ul

examination result Normal value
Random blood 107 <200 mg/dl

glucose
CKMB 32 0-24 Mg/dl
SGOT 100 0-46 Mg/dl
SGPT 63 0-45 Mg/dl
Ureum 40 10-50 mg/dl
Creatinin 1.38 0.6-1.2 mg/dl
Natrium 134.1 135-146 Mmol/l
Kalium 3.32 3.4-5.4 Mmol/l
Chlorida 97.2 95-100 Mmol/l

Working Diagnose
Etiology diagnosis : vesicolitiasis dd
ureterolitiasis
Complication diagnosis : hydro

nephrosis (S)
Clinical diagnosis : flank pain (S)
Other diagnosis : AF, VES

Management
IVFD NS 20 dpm
Venflon
Inj. Ranitidin 2x1 amp
Inj. Ketorolac 3x1 amp
Inj. Lasix 1-0-0
Po. Digoxin 1x1/2
Consult Sp. U
Consult Cardiologyst
3. Tn. Sarjani/52 years old
Chief Complain: Low back pain

History taking:
A patient came with low back pain since 1 month ago and increasing this past 2
weeks. The pain appeared suddenly and intermitten, spreading to stomatch.
There wasnt nausea and vomittus. The patient didn’t have any complain of
defecation and urination. Sandy urine, pain and burning sensation weren’t
found. Fever was denied.
• History of Past Illness : Heart failure (+)
• History of Family Illness : Heart failure (+) Hypertension (+)
•done
Vital sign
• DS : 0
• CRT 3”
• HR : 108 bpm
• RR : 28 tpm
• T : 37.1°C
• SpO2 : 98% without O2 supply
• Birth weight : 4000 gr
• Current weight : 3600 gr
• Abdominal circumference : 32 cm
Physical
Head node (-)

• I : distension (-), sausage sign (+) mass in the right abdomen,
size 3x1 cm
• A : Bowel sound (+) increase every 4 second
Abdomen • P : defance muscular (-) tenderness (+) in suprapubic region,
mass (-) ascites (-)
Extremities • warm extremities (+) edem (-)

Local State
a/r Abdomen
I : Distension (-), Lump in right quadrant size 3 x
1 cm
P : Lump hard consistency (+)
Rectal Toucher
Normal tonus of
spincter anii
Mucosa recti is
normal
Ampulla recti
collapse (-)
Nodul (-)
No feses, blood (+)
on Handscoon : feses
(+)
Pain ( - )
Laboratory
RDW-CV 16.3 12.1-14.0 %
MCV 103.7 75.0 – 96.0 fl
MCH 36.2 28.0 – 32.0 pg
MCHC 35.0 33.0 – 37.0 %
Gran% 68.3 50.0-70.0 %
Lymphocyte% 23.4 25.0-40.0 %
MID% 8.3 4.0-11.0 %

glucose
SGOT 72 0-46 U/l
SGPT 22 0-45 U/l
Ureum 7 10-50 mg/dl

PT 12.1 9.9-13,5 Second
APTT 31.7 22.2- 37 second
INR 1.12
Bilirubin Total 12.64 0.20-1.20 mg/dl
Direct Bilirubin 0.79 0.00-0.40 Mg/dl
Indirect 11.85 0.20-0.60 Mg/dl

Bilirubin
Natrium 136 135-146 Mmol/l
Kalium 5.6 3.4 – 5.4 Mmol/l
Chlorida 108 95 - 100 Mmol/l

Working Diagnose
Susp. Spigelian Hernia Impending

Inkarserata
Management
- Incubator care
- Fasting
- IVFD D10 NS 16cc/hour
- Inj. PCT 40 mg/8 hours
Consult to Pediatric Surgery :

- USG Abdomen
- Babygram
-Hospitalized in NICU
-Join care with pediatric
3. Bb. Ryan Arsyad/10
month/boy
Chief Complain: Decrease of Consciousness

History taking:
Patient came with decrease of consciousness 20 days prior to admission. Before he
reffered to Ulin Hospital, he had cough and fever 2 months ago. He also had
seizure once, 2 months ago and was hospitalized in Kapuas Hospital for 4 days. In
Kapuas Hospital, patient was diagnosed with infection in the brain then he
reffered to Ansari Saleh Hospital. In Ansari Saleh Hospital patient was
hospitalized for 40 days. In 20 days after the admission to Ansari Saleh Hospital,
patient seizure again 1 time. He was crying right after he seizure, but after few
minutes he lost his consciousness. Fever (+), cough (+). In Ansari Saleh Hospital,
his diagnosis was hidrosefalus+sepsis and severe pneumonia (improvement)
History of immunization : complete immunization
History of birth : birth spontaneously, strongly crying right after birth
Vital sign
• CRT <3”
• HR: 66 bpm
• RR: 24 tpm
• T 36.7°C
• SpO2 98% with O2 supply 2 lpm
Physical
Examination• Sclera icteric (-/-), pale conjungtiva (-/-), pupil aniskosor
Head (5mm/4mm), enlargement lymph node (-)
• Head Circumference : 41 cm
• I : symetric respiratory movement, retraction (-), bruise(-)

• I : distension (-)
Abdomen • P : defance muscular (-) tenderness (-),mass (-) ascites (-)

Laboratory
RDW-CV 19.3
MCV 80.4 75.0 – 96.0 fl
MCH 27.1 28.0 – 32.0 pg
MCHC 33.8 33.0 – 37.0 %
Gran% 40.2 50.0-70.0 %
Lymphocyte% 50.5 25.0-40.0 %
MID% 9.3 4.0-11.0 %

glucose
SGOT 96 0-46 U/l
SGPT 154 0-45 U/l
Ureum 7 10-50 mg/dl

PT 12.4 9.9-13,5 Second
APTT 26.4 22,2- 37 second
INR 1.15
Ansari Saleh Hospital (23-02-2018)
Head MSCT Interpretation
- Hypodense, diffused, and symmetric
lession in the white matter of the
bilateral frontalis, temporalis, and
parietalis lobes accompanied by
bleeding in the ganglia basalis bilateral
according to the description of the
severe diffuse hypoxic ischemic
encephalopathy
- Communicating hydrocephalus
Advice : Head MRI

Working Diagnose
DOC e.c Hidrosefalus Communicans +

Sepsis and Severe Pneumonia
(Improvement)
Management
- O2 with 2 lpm
- IVFD NS 32 cc/hours
- Inj. Meropenem 3x 350 mg
- Inj. Amikasin 1x135 mg
- Inj. Dexamethason 3x2,5mg
- Inj. Antrain 3x100mg
Consult to neuro surgery :

- Pro op Vp Shunt (28/2/18)
- Post op PICU
4. Mr. M. Sata/ 72 y.o
Chief Complain: Can not urinate

History taking:
Patient complained that he can not urinate 5 days prior to admission. Before he
reffered to Ulin General Hospital, he was admitted in Tanah Bumbu Hospital for 5
days. In Tanah Bumbu Hospital, patient used a catheter and a lot of his urine
released right after the catheter insertion. Blood in urine during catheter using (-
). He also complained that he hard to urinate. He can’t urinate smoothly and
only able to urinate little by little since 3 months ago. Pain (+) during urinate. He
need to strain to released his urine. Blood in urine (-), tea-like color in his urine (-
), fluctuative fever (+). He also said that he can’t defecated smoothly. He had to
take some medicine that inserted from his anus 3-4 times a day. Tarry stool (-),
blood in stool (-). Decreased appetite (+) 5 days prior to admission. Weight loss
(+).
History of past illness : -
Vital sign
• BP: 120/80 mmHg
• HR: 95 bpm
• RR:22 tpm
• T: 37°C
• SpO2 98% without O2 supply
Physical
Head node (-)

Abdomen • P : defance muscular (-) tenderness (+) in suprapubic region
,mass (-) ascites (-)

Urology State
Reg CVA: sign of inflamation (-), There are no palpable mass or renal
ballotemen.
Perkusi: CVA tenderness (–)
Reg suprapubic
Inspeksi : flat, hypopigmentation (-), hyperpigmentation (-), mass (-),
hematom (-), edema (-)
Palpasi : Tenderness (+), Vesica urinaria and mass are not palpable.
Regio Genitalia Externa

Penis : normal limit
Scrotum: normal limit
Perineum: normal limit
Rectal Toucher
Normal tonus of spingter anii
Mucosa recti is smooth
Prostat palpated prominent to rectum direction.
Size ± 3cm. Hard consistency. Flat surface.
Simetris. Sulcus mediana stil can be palpated.
Superior pole of prostat still can be reached by
finger.
Tenderness none
Massa: none
Handscoon feses (+) blood: (-)
Laboratory
RDW-CV 14.5
MCV 82.7 75.0 – 96.0 fl
MCH 29.1 28.0 – 32.0 pg
MCHC 35.3 33.0 – 37.0 %
Gran% 72.4 50.0-70.0 %
Lymphocyte% 16.4 25.0-40.0 %
MID% 11.2 4.0-11.0 %

glucose
SGOT 121 0-46 U/l
SGPT 61 0-45 U/l

Working Diagnose
Clinical diagnosis: Urine retention

Ethiology diagnosis: BPH dd Ca prostat
Complication diagnosis: -
Other diagnosis: Anemia
Management
IVFD NaCl 20 dpm
Inj. Ceftriaxon 2x1gr
Inj. Ketorolac 3x30 mg
Inj. Ranitidin 2x50mg
Consult to Urology :
5. Mr. Masran/ 49 y.o
Chief Complain: Decrease of conciousness

History taking:
Patient came with decrease of consciousness 5 hours prior to ER
admission. He was suddenly unconscious after eating with his
friend in the market. He was immediately brought to Pelaihari
Hospital to get treated. He reffered to Ulin hospital to assessed
further due to limitation of CT scan facilitation. He complained that
he had headache since 2 weeks ago but didn’t take any medication.
Vomiting (-). History of trauma (-). He had history of uncontrolled
blood pressure for years. High blood glucose (+), high uric acid (+).
He consumed high blood glucose medication sometimes but not
Vital sign
• GCS E1V2M3
• BP 165/85 mmHg
• HR 103 bpm
• RR 18 tpm
• T 36.5°C
• SpO2 96% with O2 10 lpm NRM
Physical
Head node (-)

Abdomen • P : defance muscular (-) tenderness (-) ,mass (-) ascites (-)
Extremities • warm extremities (+) edem (-)

Clinical
Picture
Laboratory
Hemoglobin 11.00-16.00 g/dl
Leucocyte 4.0-10.5 Thousand /ul
Erytrocyte 4.50-6.00 milion /ul
Hematocrit 42.00-52.00 Vol%
Trombocyte 150-450 Thousand /ul
RDW-CV
MCV 75.0 – 96.0 fl
MCH 28.0 – 32.0 pg
MCHC 33.0 – 37.0 %
Gran% 50.0-70.0 %
Lymphocyte% 25.0-40.0 %
MID% 4.0-11.0 %
Gran# 2.50-7.00 Thousand/ul
Lymphocyte# 1.25-4.0 Thousand/ul
MID# Thousand/ul

glucose
SGOT 0-46 U/l
SGPT 0-45 U/l
Ureum 10-50 mg/dl
Creatinin 0.6-1.2 mg/dl

PT 9.9-13,5 Second
APTT 22,2- 37 second
INR
Natrium 135-146 Mmol/l
Kalium 3.4 – 5.4 Mmol/l
Chlorida 95 - 100 Mmol/l
Uric Acid
Working Diagnose
IVH ICH (GCS 6) e.c Stroke Hemorrhage

+ DM type II + Gout Arthritis
Management
Head Up 30° From Neurology department
O2 NRM Inj. Ceftriaxone 2x1 g
Program Manitol 6x100 cc
IVFD NaCl 0,9% 20 tpm
Consult to neuro surgery
Inj. Citicoline 3x250 mg
Inj. Ranitidine 2x1 amp
Inj. Metoclopramide 3x10 mg Consult to Neuro Surgery :
Drip Nicardipine 15 cc/hou Pro op EVD CITO
Inj. Novorapide 10 cc SC Hospitalized to ICU post oper
DC, NGT
6. Mr. Firman/25 y.o
Chief Complain: Pain on the leg

History taking :
Patient came with pain on the left leg since 10 days prior to admission. There
are active bleeding in his left leg. He was a reffered patient from Doris
Hospital, Palangkaraya. In Doris Hospital, her wound was treated with
hecting and spalk. He was planned to gone for ORIF elective in Doris Hospital
but due to the limited facilitation the operation can’t be held in there and he
reffered to Ulin General Hospital. He was in a motorcycle accident 10 days
ago. His motorcycle hit another motorcycle. He was wearing helmet during
the accident. Patient also complained pain in the face area since 5 days ago.
He also said that he can’t clinch his teeth.
History of past illness :

Physical
Head node (-)


Regio maxillofacial
A/r orbita d/s : deformitas (-/-) swelling(-/-), hematom (-)
A.r. temporal : deformitas (-/-) swelling(-/-), hematom (-) krepitasi (-)
A.r. frontalis : deformitas (-/-) swelling(-/-), hematom (-) krepitasi (-)
At zygoma d/s : deformitas (-/-), swelling (-/-) krepitasi (-/-)
At maxilla (d/s) : hematom (-/-), swelling (-/-) krepitasi (-/-) krepitasi (-/-) bleeding (-/-)
floating (-)
At mandibula : hematom (-), eksoriasi (-), deformitas (-/+) crepitasi (-),swelling (-)
malocclution (+)
At nasal : deformitas (-), swelling (-), flattening (-) crepitasi (-)
At labia oris superior : normal limit
At labia orisninferior : normal limit
Ar intra oral: normal limit

a/r cruris Sinistra
L : Deformity (+), Swelling (+),
hyperemis (+), wound (+),
Stitch (+), Pus (+), Bloody (-)
F : (-)
Active and passive ROM
limited due to pain
Laboratory
RDW-CV 12.9
MCV 88.2 75.0 – 96.0 fl
MCH 31.8 28.0 – 32.0 pg
MCHC 36.1 33.0 – 37.0 %
Gran% 77.6 50.0-70.0 %
Lymphocyte% 13.4 25.0-40.0 %
MID% 9.0 4.0-11.0 %

glucose
SGOT 48 0-46 U/l
SGPT 52 0-45 U/l

PT 12.5 9.9-13,5 Second
APTT 26.9 22,2- 37 second
INR 1.15
Working Diagnose
MHI (GCS 15) + Open Fracture tibia

segmental 1/3 middle GA gr 2 sinistra +
Close fracture 1/3 proximal sinistra +
Fracture corpus mandibular sinistra
Management
Immobilization
IVFD NS 20dpm
Inj. Ceftriaxone 2x1gr
Inj. Metronidazole 3x500mg
Inj. Keterolac 3x1
Inj. Ranitidin 2x1
Co to Orthopedic :
OREF CITO
Co to Plastic Surgery :
ORIF elective
Co to Neuro Surgery :
No treatment
7. Mr. Ari Yustisio/19 y.o
Chief Complain: abdominal pain
History taking:
Patient complained that he got abdominal pain 6 hours prior to admission. Intially,
the felt was in epigastric region and moved to the right side of the abdomen. The
pain was stabbing and continuously. Bloating stomatch (+) 6 hours prior to
admission. Vomiting (+) 5 times. The vomit containing the food that he ate.
Blood (-). Defecation (+) 5 hours prior to admission. The color of the stool is dark
yellow, blood (-), liquid stool (-), separated lump appereance (-), flatus (-). History
of fever (+) 1 day prior to admission, nausea (+). He also had history of
appendectomy operation in Ulin Hospital 4 months ago.
History of past illness :
History of family illness :
Vital sign
• BP 110/70 mmHg
• HR 84 bpm
• RR 22 tpm
• T 37.9°C
• SpO2 98% without O2 supply
Physical
Head node (-)

• I : distension (+)
Abdomen • P : defance muscular (+) tenderness (+) in all region ,mass (-)
ascites (-)

a/r Abdomen:
I : distention (+), Scars post
appendectomy (+)
P : Tenderness (+) all region
abdomen, defance muscullar (+)
Laboratory
RDW-CV 18.3
MCV 70.6 75.0 – 96.0 fl
MCH 22.9 28.0 – 32.0 pg
MCHC 32.5 33.0 – 37.0 %
Gran% 91.3 50.0-70.0 %
Lymphocyte% 4.8 25.0-40.0 %
MID% 3.9 4.0-11.0 %

glucose
SGOT 39 0-46 U/l
SGPT 20 0-45 U/l

Working Diagnose
Abdominal pain e.c peritonitis e.c susp.

Adhesi post appendictomy
Management
IVFD RL 20 dpm
Inj. Ceftriaxone 2x1gr
BNO
Consult To Digestive Surgery :

8. Mr. Supriyanto/ 35 y.o
Chief Complain:
Bloody nose
History taking:
Patient came with bloody nose since 1 hour prior to admission. Bloody nose appear
suddenly after he got traffic accident. He got accident while riding motorcycle.
His motorcycle was bumping another motorcycle. At that time, he did not
wearing helmet while riding the motorcycle. He was riding motorcycle at the left
side of the street and said that he did not against the direction. Patient was fall
and crashed, but he did not remember the detail about how he fell. Decrease of
consciousness (-), nausea (-), vomiting (-), headache (+).
History of past illness : (-)
History of family illness : (-)
Primary survey
A: clear, without c spine control

B: RR: 21 tpm, reguler, rh(-/-) wh(-/-), SpO2 98% without
O2 supply
C: N: 85 bpm, strong pulse, TD: 130/80 mmHg
D: GCS 15 E4V5M6, BH (-|-) BS(-|-) BO (-|-) BR (+/+)
Secondary survey
A: Allergy (-)
M: Alcohol
P: History of Disease (-)
L: 19:30
E: On the road
Physical
Head node (-), deformity (+) a/r nasal


Local State
Regio maxillofacial
1. A/r orbita d/s : deformity (-/-), swelling(-/-), hematom (-)
2. A.r. temporal : deformity (-/-), swelling(-/-), hematom (-), crepitation (-)
3. A.r. frontalis : deformity (-/-) swelling(-/-), hematom (-) crepitation(-)
4. At zygoma d/s : deformity (-/-), swelling (-/-) crepitation (-/-)
5. At maxilla (d/s) : hematom (-/-), swelling (-/-) crepitation (-/-) crepitation (-/-)
bloody (-/-) floating (-) VL + 2cm (patient refused to perfomed acting)
6. At mandibula : hematom (-), eksoriasi (-), deformity (-) crepitation (-),swelling (-)
malocclution (-)
7. At nasal : deformity (+), deviation to the right, swelling (+), flattening (+) bleeding
(+/+), crepitation (-)
8. At labia oris superior : normal limit
9. At labia oris n inferior : normal limit
10. Ar intra oral: normal limit
Laboratory
RDW-CV 13.0
MCV 92.4 75.0 – 96.0 fl
MCH 32.6 28.0 – 32.0 pg
MCHC 35.3 33.0 – 37.0 %
Gran% 88.1 50.0-70.0 %
Lymphocyte% 7.1 25.0-40.0 %
MID% 4.8 4.0-11.0 %

Working Diagnose
Susp. Fracture Nasal + VL a/r Facialis

Management
IVFD NS 30 dpm
Inj ketorolac 2x30 mg
Inj ranitidin 2x 50 mg
Inj ceftriaxon 2x1 gr
Consult to Plastic surgery :

Emergency Room Morning Report: March 25 26 2018

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Emergency Room Morning Report: March 25 26 2018

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Emergency Room

Thorax Cardiovascular Surgery : -

Urology Surgery : 1 patient

1 Child Raffi March 25th open fracture at IVFD RL 20 dpm

• I : wound (-), symetric respiratory movement, retraction (-),

• warm extremities (+)

A/r antebracii dextra

open fracture at right ulna

Co. orthophaedic surgery:

History of Past illness:

History of family illness: There is no same complains with patient

• I : symetric respiratory movement, retraction (-), bruise (-)

Extremities • warm extremities (+)

Urology • Inspection: mass (-/-), hematom (-/-), bruise (-)

• Inspection : suprapubic bulge (-), scars (-), hematom (-) mass

• OUE : bloody discharge (-), edem (-), catheter (-)

Hemoglobin 12.2 14.00-18.00 g/dl

Leucocyte 5.2 4.00-10.5 103 /ul

Eritrocyte 5.11 4.10-6.00 million/ul

RDW-CV 18.3 12.1-14.00 %

MCV, MCH, MCHC

MCV 72.1 75.0-96.0 fl

MCH 23.8 28.0-32.0 pg

MCHC 33.1 33.0-37.0 %

Lymphocyte# 1.7 1.25-4.0 thousand/ul

Clinical : Right abdominal pain

Chief Complain: Low back pain

• I : symetric respiratory movement, retraction (-), bruise (-)

• warm extremities (+)

Lymphocyte% 13.7 25.0-40.0 %

MID% 10.1 4.0-11.0 %

Gran# 8.2 2.50-7.00 Thousand/ul

Lymphocyte# 1.5 1.25-4.0 Thousand/ul

MID# 1.1 Thousand/ul

Random blood 107 <200 mg/dl

SGOT 100 0-46 Mg/dl

SGPT 63 0-45 Mg/dl

Ureum 40 10-50 mg/dl

Creatinin 1.38 0.6-1.2 mg/dl

Natrium 134.1 135-146 Mmol/l

Kalium 3.32 3.4-5.4 Mmol/l

Chlorida 97.2 95-100 Mmol/l

Complication diagnosis : hydro

Clinical diagnosis : flank pain (S)

Other diagnosis : AF, VES

Chief Complain: Low back pain

• I : symetric respiratory movement, retraction (-), bruise (-)

Extremities • warm extremities (+) edem (-)

Lymphocyte% 23.4 25.0-40.0 %

MID% 8.3 4.0-11.0 %

Gran# 13.4 2.50-7.00 Thousand/ul

Lymphocyte# 4.6 1.25-4.0 Thousand/ul

MID# 1.6 Thousand/ul

Random blood 65 <200 mg/dl

SGPT 22 0-45 U/l

Ureum 7 10-50 mg/dl

Creatinin 0.66 0.6-1.2 mg/dl

PT 12.1 9.9-13,5 Second