EMERGENCY CASE REPORT

13th – 14th June 2019

Presented by the A
Team:
Muntay, Rifqi, Tasya, Ridho, Icha,
Galuh, Tania, Alya,
General Surgery :-
Digestive Surgery : 1 patient

Thorax Cardiovascular Surgery : -

Plastic Surgery :-

Urology Surgery :-

Neuro Surgery : 1 patient

Pediatric Surgery : 1 patient

Oncology Surgery : 1 patient

Orthopaedic : 1Patients

Total : 5 patients
 Patient List
No Identity/Age Problem list Diagnose Treatment

1. Ch. Ahmad Decrease of DOC + Treatment in ER :

Jalalludin/13 consciousness hydrocephalus IVFD Nacl 0,9% 14 tpm
YO comunicans e.c Inj. Amikasin 1x300 mg
recurrent Inj. Citicolin 3x125 mg
Chief astrocytoma Inj. Meropenem 3x1 gr
Complain: Inj. Antrain 250 mg (k/p)
Fluid diet with pediasure 8x80 cc
Decrease of Fruit juice 1x35 cc
consciousness
• Consult Neurosurgery
• Hospitalized
 Patient List
No Identity/Age Problem List Diagnose Treatment

2. Mrs. pain in the right Closed fracture at • Treatment in ER :

Salbiah/41 shoulder right clavicle distal • Wound toilet
YO 3rd Allman group II • Po. Amoxicilin 3 x 500mg
oblique • Po. Mefenamic Acid 3 x 500mg
Chief undisplaced • Patient out by request
Complain:
pain in the Co. to Orthopaedic Surgery:
right • Conservative treatment
shoulder • Immobilization with arm sling
 Patient List
No Identity/Age Problem list Diagnose Treatment
3. Ch.Mrs. • Abdominal Suspect • Treatment in ER
Susilawati / distension Hirschsprung • Balance Fluid: IVFD D10
10 day Disease + Close 300cc/24hours
Fracture of right • Abdominal decompression
clavicle middle 3rd • Fasting
Chief Oblique displaced • Wash out 2x/day
complain: • Pro Colon in loop and
Abdominal retension
distension • Join care with Perinatology
and Ortopaedic

Co to Pediatric Surgery:
• Hospitalized

Co to Ortopaedic:
• Conservative treatment by
immobilization with arm
sling
 Patient List
No Identity/Age Problem list Diagnose Treatment

4. Mr. Bleeding from Tumor Colli Sx Treatment in ER:

Burhan/57 the left neck suspect Malignant Loading RL 1500 cc
YO lump + Shock IVFD RL 2000cc/24hours
hypovolemic rapid Inj. Tranexamat Acid 3x500mg
Chief response Inj. Ranitidine 2x50mg
Complain: Inj. Ketorolac 3x30mg
Bleeding PRC transfusion 2 kolf/days until hb >10
from the left
neck lump Consult to Oncology:
Hospitalized
No Identity/Age Problem list Diagnose Treatment

5. Mrs. General peritonitis Treatment from ER

Rahati/85 YO abdominal pain ec susp Hollow IVFD Nacl 0,9% 1 line (loading 1000cc)
viscus + Susp TB Inj. Ceftriaxone 2x1 gr
Chief Pulmo+ Acute Inj. Metronidazol 3x500mg
Complain: Kidney Injury Inj. Antrain 3x1gr
Inj. Ranitidine 3x1 amp
abdominal DC, NGT
pain
Consult to Pulmonology :

Consult to Digestive Surgery :

Pro CITO Laparotomi
Post Op in ICU
 1. Ch. Ahmad Jalalludin/13 yo/MR 0664143
Admitted June 13th 2019 at 05.30 PM
Chief Complain : Decrease of consciousness
History taking : Patient was referral from Ansari Saleh Hospital. Patients came with
his parent because complaints of decreased consciousness since 18 days of before
admitting to hospital. The patient has been treated at the Ansari Saleh Hospital for
1 month. At first patient complaints with vomiting since 2 months of ago. Since then
patient's condition appears to be weakening and the patient were treated for 1
month. Seizures and decreased consciousness are denied. Since +/- 1 month before
admitting to hospital (May 16th, 2019) patients are being treated at Anshari Saleh
Hospital, for the first 10 days of treatment the patient is still conscious. However,
since May 26, 2019, patient awareness has declined until now.

History of Past illness : Patients had history of surgery twice which was November 2016
and January 2019 due to Astrocytoma. According to his parent he had tumor
removal surgery.
History of Family Illness: Malignancy (-)
 Vital Sign

BP : 130/100 mmHg
HR : 148 bpm (regular, strong)
RR : 22 bpm
Tax : 37,3 0C
GCS : E3VxM5
SpO2 : 98% without 02 Supply
Physical Examination
• Sclera icteric (-/-), pale conjungtiva (-/-), pupil unequal 4 mm|3 mm, light
Head reflex (+|+) minimal

• I : symetric respiratory movement, retraction (-)

Chest • P : sonor at all lung fields
• A : symmetric VBS, rhonchi (-), wheezing (-)

• I : distension (-)
• A : bowel sound (+) normal
Abdomen • P : soft, tenderness (-), defense muscular (-) tenderness (-) mass (-) ascites
(-)
• P : tympani at all region

Extremities • warm extremities (+), edema (-), paresis (-), lateralization (-)
Neurological State

 GCS E3VxM5
 Pupil unequal 4 mm|3 mm, minimal light reflex
 Meningeal sign (-)
 Babinsky reflex (+)
 Lateralization (-)
Clinical Picture
 Laboratory Finding
Examination Result Normal Value
Hemoglobin 16,8 12,00-16,00 g/dl
Leukosit 7,7 4,0-10,5 ribu/ul
Eritrosit 5,99 3,90-5,50 juta/ul
Hematokrit 48,1 37,00-47,00 vol%
Trombosit 355 150-450 ribu/ul
RDW-CV 12,4 11,5-14,7 %
MCV 80,3 80,0-97,0 f
MCH 28 27,0-32,0 pg
MCHC 34,9 32,0- 38,0 %
Gran% 73
Limfosit% 10,6
Monosit% 12,6
Gran# 5,62
Limfosit# 0,82
Monosit% 0,97
 Laboratory Finding
Examination Result Normal Value

PT 12,8 9.9 -13.5 detik

Control Normal PT 10,8
APTT 24,1 22.2- 37.0 detik
Control Normal APTT 24,8
INR 1,2
Random Blood Glucose 113 <200.00 mg/dl
SGOT 26 5-34 u/l
SGPT 18 0-55 u/l
Ureum 12 10-50 mg/dl
Creatinin 0,19 0.6-1.2 mg/dl
Natrium 130 135-146 mmol/L
Kalium 4,3 3,4-5,4 mmol/l
Chlorida 86 95-100 mmol/l
Non-contrast and contrast CT Scan
28/01/2019 at Ansari Saleh Hospital
Non-contrast Head CT Scan 11/06/2019 at
Ansari Saleh Hospital
 Diagnosis
DOC + hydrocephalus comunicans e.c recurrent
astrocytoma
Management

Treatment in ER :
 IVFD Nacl 0,9% 14 tpm
 Inj. Amikasin 1x300 mg
 Inj. Citicolin 3x125 mg
 Inj. Meropenem 3x1 gr
 Inj. Antrain 250 mg (k/p)
 Fluid diet with pediasure 8x80 cc
 Fruit juice 1x35 cc
Consult Neurosurgery
 Hospitalized
 2. Mrs. Salbiah/41 yo/MR 1430662
Admitted June 13th 2019 at 06.00 PM
Chief Complain: Pain in right shoulder

History taking
Patients came with complaints pain at right shoulder after a motor vehicle accident 7 hours
before entering the hospital. Patients riding motorbikes with her husbands and using helmets,
motorbikes driven at high speed in rainy day and slipping vehicles resulted in motorbikes falling
together with her husbands. Shoulders hit the road and face exposed to asphalt. decreased
consciousness (-), nausea / vomiting (- / -), blurred vision (-), limb weakness (-). According to the
patient the shoulder could not be moved and it was brought to the masseur and get figure of
eight splint.

History of Past Illness : (-)

History of Family Illness : (-)
Primary Survey
 Airway :
 Clear, gurgling (-), Snoring(-) with C-Spine control
 Breathing :
 Lesion (-), symmetrical chest movement, tracheal deviation (-), jugular vein distension (-), RR : 20x/minute
(regular), Vesicular breath sound both side. SpO2 : 98% without O2 supply.
 Circulation :
 Pulse : 99x/minute (weak, regular), CRT < 3”, warm extremities, external hemorrhage (-)
 Disability :
 GCS E4V5M6, pupils equal 3 mm/3 mm, direct light reflex (+/+), indirect light reflex (+/+), lateralization (-/-),
BO (-/-), BR (-/-), BS (-/-), BH (-/-)
Secondary Survey

 Allergy : (-)
 Medication : (-)
 Past Illness : (-)
 Last Meal : 11.00 AM
 Environment : Handil bakti, Banjarmasin
 • Eye : sclera icteric (-), pale conjungtiva (-/-), pupil equal (3mm/3mm), lights
refleks (+/+), subconjuntiva bleeding (-|-)
Head & Neck • bloody rinorrhea (-/-), bloody otorrhea (-/-)
• enlargement lymph node (-), lesion (-), edema (-|-)

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

Chest • P : sonor at all lung fields
• A : VBS, ronchi (-/-), wheezing (-/-)

• I : distension (-), lesion (-), bruise (-)

• A : bowel sound (+) 6x/minutes
Abdomen • P : soft, defense muscular (-) tenderness hard to evaluate, liver and spleen
not palpable
• P : tympani at all region

Extremities • Cold extremities (+), edema (-|-), lateralization (-/-)

 Maxillofacial Status
• I : Hematoma (-/-), Deformity (-), swelling (-) VE (+)
a/r frontalis • P: Tenderness (hard to evaluate), crepitation (-)

• I : Hematom palpebral(-), visus OD/OS (hard to evaluate), eye movement

a/r rima orbita (hard to evaluate), subconjungtiva bleeding (-/-)
• P : Tenderness (hard to evaluate), crepitation (-/-)

• I : Hematoma (-), epistaxis (-/-), deformity (-), swelling (-) VE (+)

a/r nasalis • P : Tenderness (hard to evaluate), crepitation (-)

• I : Hematoma (-/-), Deformity (-), swelling (-/-), VE (+) at Philtrum

a/r maxillaris • P : Tenderness(hard to evaluate), crepitation (-/-), floating maxilla (-)

• I : Hematoma (-/-), Deformity (-), swelling (-/-), VE (+/+)

a/r zygoma • P : Tenderness (hard to evaluate), crepitation (-/-)

• I : Hematoma (-/-), Deformity (-/-), swelling (-/-)

a/r mandible • P : Tenderness (-/-), crepitation (-/-), stable mandibula
• I : Hematoma (-/-), bleeding (-), fraktur palatina (-), maloclusion (hard to
evaluate)
a/r intraoral • P : alveolar bone unstable a/r insicivus I dex inferior s/d molar I sx inferior,
tenderness (hard to evaluate)
Local State at right shoulder

 Look :
 deformity (+), wound (-),
swelling (+), hematoma (-)
 Feel :
 tenderness hard to evaluated,
distal artery (+), CRT < 3”,
sensory hard to evaluated
 Move :
 Rom at right shoulder limited
due to pain
Clinical Picture
Shoulder X ray at Ulin Hospital,
June 13th 2019
Diagnosis
Closed fracture at right clavicle distal 3rd Allman group II oblique undisplaced
Management
Treatment in ER :
Wound toilet
Po. Amoxicilin 3 x 500mg
Po. Mefenamic Ac 3 x 500mg
Patient out by request

Co. to Orthopaedic Surgery:

Conservative treatment
Immobilization with arm sling
 3. Bb. Mrs. Susilawati/10 days/MR
1430670
Admitted June 13th 2019 at 07.00
PM
Chief Complain: abdomen distension
History taking:
Patient came with his parent because of abdominal distension for 8 days before entering the hospital.
At birth, according to the mother the baby has an anus and can defecate. At the age of 2 days the
stomach becomes bloated. White vomiting 3 days ago. Hospitalized for 6 days at Tanjung Hospital,
the patient had OGT installed and then his stomach was flat, and OGT was released after 6 days of
installation. Then he was given 20cc breast milk and then bloated again.
History of mother pregnancy:
 G3P2A0 39-40 weeks, routinely ANC to midwife every month
 Ilness during pregnancy is denied, comcumtion alcohol (-), smoking (-), history of polyhidramnion
(-)
History of birth :
 Babies born spontanius breech in Muara Tewewh Hospital with birth weight 3200 gr, strong cry and
active movement, APGAR score 7-8-9.
 Inj Vit K (+) Imunitation HB0 (+)
 Vital Sign

Compos mentis
HR: 142 bpm
RR: 49 bpm
T: 36,6oC
CRT < 3”
Sp O2: 98% without O2
 Physical
Examinati
• Sclera icteric (-/-), pale conjungtiva (-/-), pupil equal
Head (3mm/3mm), enlargement lymph node (-)
on
• I : symetric respiratory movement, retraction (-), bruise(-)
• P : difficult evaluation
Chest • P : Sonor at all lung fields
• A : symmetric VBS, rhonchi (-), wheezing (-)
• I : distension (+) , venectation (+), damn contour (-),
dry umbilical chord.
Abdomen • A : Bowel sound (+) increase (15x/ mnt)
• P : firm consistency, H/M/L hard to evaluate
• P : hypertymphani at all region

• warm extremities (+)

Extremities • Edem (-)

Genital • Penis (+)

Vertebral anomalies (-)

Anorectal malformation (-)

Congenital cardiac defects (-)

Tracheo-Esofageal anomalies
(-)

Renal - urinary anomalies (-)

Limb defects (-)

Digital rectal examination

Inspection:
 anus (+)
 meconium (+)
 mass (-)
 fistula (-)
Palpation:
 Smooth rectal mucosa
 Normal spincter anal
 Normal ampulla recti
Clinical picture
Baby Gram
 Laboratory Finding

Pemeriksaan Hasil Nilai Rujukan

Hemoglobin 15,4 12,00-16,00 g/dl
Leukosit 14,6 4,0-10,5 ribu/ul
Eritrosit 4,59 3,90-5,50 juta/ul
Hematokrit 44,1 37,00-47,00 vol%
Trombosit 292 150-450 ribu/ul
RDW-CV 14,6 11,5-14,7 %
MCV 96,1 80,0-97,0 fl
MCH 33,6 27,0-32,0 pg
MCHC 34,9 32,0- 38,0 %
Gran % 29,8 50,0-70,0 %
Limfosit % 50,9 25,0-40,0 %
Monosit % 18,3 4,0-11,0 %
Gran # 4,35 2,50-7,00 ribu/ul
Limfosit # 7,42 1,25-4,0 ribu/ul
Monosit # 2,66
 Pemeriksaan Hasil Nilai Rujukan

PT 17,4 9,9-13,5 detik

INR 1,63

APTT 39,9 22,2-37,0 detik

GDS 54 <200

SGOT 48 0-46 U/l

SGPT 25 0-45 U/l

Ureum 8 10-50 mg/dl

Creatinin 0,59 0,7-1,4 mg/dl

Natrium 141 135-146 mmol/l

Kalium 3,8 3,4-5,4 mmol/l

Chlorida 106 95-100 mmol/l

Total Bilirubin 2,7 0,0 – 15 mg/dl

Direct 0,63 0,0 – 0,6 mg/dl

Indirect 2,07 0,2 – 0,8 mg/dl

Working Diagnose

Suspect Hirschsprung Disease +

Close Fracture of right clavicle
middle 3rd Oblique displaced
Management
Treatment in ER
 Balance Fluid: IVFD D10 300cc/24hours
 Abdominal decompression
 Fasting
 Wash out 2x/day
 Pro Colon in loop and retension
 Join care with Perinatology and Ortopaedic

Co to Pediatric Surgery:
 Hospitalized

Co to Ortopaedic:
 Conservative treatment by immobilization with arm sling
 4. Mr. Burhan/ 57 yo/ MR 1430537
Admitted June 13th 2019 at 08.00 PM

Chief Complain : Bleeding from the lump

History :
Patients came with bleeding, bleeding came from the left neck lump since 30 minutes
before admitting to Hospital, bleeding occurs suddenly and occurs continuously. The
lump appeared since 1 year ago, initially a lump size pingpong balls. Since the last 4
months ago lump has grown to reach the size of takraw balls. The lump was felt thick
and painless, as long as the lump appears the patient complains of difficulty swallowing,
every cough tries to swallow food, and hoarse voice.
History of Pass Illness: HT (-), DM (-)
History of Surgery: patient has a history of 2 times incisional biopsy surgery in February
2019 and May 2019
History of Soscial life: Patient is a farmer, smoker (+) and has stopped since 2 years ago
Vital Sign

 BP : 120/70 mmHg
 HR : 102 bpm (regular, strong)
 RR : 20 tpm
 Tax : 36,30C
 SpO2 : 98% without O2
 Karnofsky Score : 50-60%
 VAS : 2/10
Physical
Examination
• Head : pale conjunctiva (+|+), light reflex (+|+), sclera icteric (-/-)
• Mouth : Moist mucous membrane
Head • Neck : Mass with hard consistency, immobile, rough surface, Tenderness
(-), active bleeding (+) >> stop with direct pressure

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

Chest • P : Sonor
• A : Vesicular Breath Sound, no ronchi , no wheezing

• I : distension (-), mass (-)

• A : bowel sound (+) normal
Abdomen • P : soft, tenderness (-), liver and Spleen not palpable, mass (-).
• Per : timpani at all regio

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

Localized Status

 I : Swelling (-), Edem (-), Mass (+)

in m. Sternocleidomastoid hard
consistency, immobile, rough
surface, Tenderness (-), active
bleeding (+) >> stop with direct
pressure size 20x15x8 cm, Ulcus
(-)
 P: tenderness (+) hard consistency,
immobile, rough surface
Clinical picture
Histopathology
Laboratory Finding 13/6/19
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 7,3 12,00-16,00 g/dl
Leukosit 10,9 4,0-10,5 ribu/ul
Eritrosit 2,6 3,90-5,50 juta/ul
Hematokrit 22 37,00-47,00 vol%
Trombosit 424 150-450 ribu/ul
RDW-CV 11,9 11,5-14,7 %
MCV 84,6 80,0-97,0 fl
MCH 28,1 27,0-32,0 pg
MCHC 33,2 32,0- 38,0 %
Gran% 54,1 50 – 81 %
Limfosit% 28,8 20 – 40 %
Monosit% 9,8 2–8%
Gran# 5,86 2,5 – 7,0
Limfosit# 3,13 1,25 – 4,00
Monosit# 1,06 0,3 – 1,0
 Laboratory Finding 13/6/19

Pemeriksaan Hasil Nilai Rujukan

PT 11,2 9,9-13,5 detik

INR 1,04

APTT 26,5 22,2-37,0 detik

GDS 213 <200

SGOT 19 0-46 U/l

SGPT 11 0-45 U/l

Bil tot 24 0.2-1.20 mg/dl

Bil Direct 1,02 0,0-0.20 mg/dl

Natrium 133 135-146 mmol/l

Kalium 4,0 3,4-5,4 mmol/l

Chlorida 98 95-100 mmol/l

 Working Diagnosis

Tumor Colli Sx suspect Malignant + Shock

hypovolemic rapid response
Management

Treatment in ER:
 Loading RL 1500 cc
 IVFD RL 2000cc/24hours
 Inj. Tranexamat Acid 3x500mg
 Inj. Ranitidine 2x50mg
 Inj. Ketorolac 3x30mg
 PRC transfusion 2 kolf/days until hb >10
Consult to Oncology:
 Hospitalized
 5. Mrs. Rahati/85 yo/MR 1430688
Admitted June 14th 2019 at 04.00 AM

Chief Complain: Abdominal pain

History taking:
Patients came with complaints abdominal pain since 2 days ago, pain was felt all region of
abdominal area. Previously in the last 2 months, patients also had difficulty defecating, defecating
slightly hard and small round blackish brown. Since 2 days ago, she were not farting and not
defecating. Stomach also appears to have enlarged since 2 days ago. Complaints of nausea and
vomiting are denied. The patient is no longer able to move because of pain in his stomach.
Patient also has a lump on the right cheek since + - 30 years. Size enlarges slowly, no pain (-). The
patient often drinks a mixture Benalu’s roots due to his lump in his neck.

History of Past Illness : HT (+) uncontrolled, DM (-) History of TB approximately 35 years ago taking
medication for only 1 month, Gastritis (+)
History of Family Illness : (-)
Vital Sign

BP : 100/50 mmHg
RR : 32 tpm
HR : 109 bpm, weak and regular pulse
Temp : 36,2oC
VAS : 6/10
SpO2 : 98% with O2 supply Masker 10 lpm
Physical Examination
• pale conjungtiva (-/-), sclera icteric (-/-), pupil equal, NGT (+) 16 fr there’s
no production in NGT, macula hipopigmentasion (+)
Head/Neck • enlargement lymph node (-)
• Mass (+) ar Mandible dx, size 11x12x5cm, mobile mass with soft consistency,
regular border.

• I : symmetric respiratory movement, retraction (-), bruise (-), macula

hipopigmentasion (+)
Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (+/+), wheezing (-)

• I : distension (+) , scar (-), pus (-), mass (-), inguinal mass (-) Urin catheter
16 Fr with Urin inisial 60cc
Abdomen • A : bowel sound (+) decrease, 1-2x/minute
• P : defance muscular (+), liver / spleen / mass hard to evalutaed
• P : hypertymphani

Extremities • cold extremities, parase (-), edem (-)

Digital Rectal Examination

I : haemorrhoid (-), laceration (-), mass (-), fistle (-)

P:
 Weak spincter tone
 Mucosa was not slippery
 Ampulla was collapse
 Mass (-) Feel feces in the rectum
 Handscon : Feces (+), blood (-)
Clinical Picture
 Laboratory Finding June 14th 2019
Examination Result Normal Value
Hemoglobin 9,9 12,00-16,00 g/dl
Leukosit 12,6 4,0-10,5 ribu/ul
Eritrosit 4,67 3,90-5,50 juta/ul
Hematokrit 34,5 37,00-47,00 vol%
Trombosit 324 150-450 ribu/ul
RDW-CV 18,7 11,5-14,7 %
MCV 73,9 80,0-97,0 f
MCH 21,2 27,0-32,0 pg
MCHC 28,7 32,0- 38,0 %
Neutrofil ribu/ul
Limfosit 0,7 ribu/ul
Monosit ribu/ul
Neutrofil% %
Limfosit% 5,2 %
Monosit% %
 Laboratory Finding (June 14th 2019)
Examination Result Normal Value

GDS 76 <200
SGOT 36 0-46 U/l
SGPT 16 0-45 U/l
Ureum 117 10-50 mg/dl
Creatinin 4,38 0,7-1,4 mg/dl
PT 15,3 9.9-13.5 detik
APTT 30,1 22.2-37.0 detik
INR 1,44 -
Natrium 139 136-145 Meq/L
Kalium 5,0 3.5-5.1 Meq/L
Chloride 105 98-107 Meq/L
 Urinalysis June 14th 2019
Examination Result Normal Value

Color - turbidity Cloudy-yellowish Clear-yellow

Density 1,030 1,005 -1,030
pH 6,0 5.0 -6.5
Ketone Negative Negative
Protein-Albumin 1+ Negative
Glucose Negative Negative
Bilirubin Negative Negative
Blood Negative Negative
Nitrit Negative Negative
Urobilinogen 0,1 0,1-1,0
Leucocyt Negative Negative
Urinalysis June 14th,2019
Examination Result Normal Value

Lekosit 1–2 0–3

Eritrosit 1–2 0–2
Epithel 1+ 1+
Crystal Negative Negative

Silinder Negative Negative

Bacteria 3+ Negative
Other Negative Negative
Chest X-Ray (June 14th 2019)
Abdoment 3 Position June 14th 2019
Diagnosis
General peritonitis ec susp Hollow viscus + Susp TB Pulmo+ Acute Kidney
Injury
Management

 Treatment from ER
 IVFD Nacl 0,9% 1 line (loading 1000cc)
 Inj. Ceftriaxone 2x1 gr
 Inj. Metronidazol 3x500mg
 Inj. Antrain 3x1gr
 Inj. Ranitidine 3x1 amp
 DC, NGT
 Consult to Pulmonology
Consult to Digestive Surgery :

Pro CITO Laparotomi

 Post Op in ICU
Thank you