Emergency Case Report April 9th-10th 2013

Resident on Duty : dr. Alex Chief Co-Assistant : Hendra Team : Arif ZN, Diny, Rachma, Aina

Minor Surgery Digestive Surgery

: :

Thorax Cardiovascular Surgery : Plastic Surgery

Urology Surgery Neurosurgery Pediatric Surgery Oncology Surgery Orthopaedi Total

:
: : : : : :

Patients List
No. 1 2. Identity Admission to E.R. Diagnosis Treatment / Planning Mr. M. Yusran / April 9th 2013 53 yo at 14.15 Mr. Khairudin / April 9th 2013 32 yo at 16.55

3.

Mr. Sunaryo / 60 yo An. Ali Yasir / 8 yo

April 9th 2013 at 17.10 April 9th 2013 at 18.00

4.

5.

Mrs. Ramsidah April 9th 2013 at 18.35 / 51 th

Patients List
No. 5. Identity Mr. Hadarani / 71 yo Admission to E.R. April 9th 2013 at 23.38 Diagnosis Treatment / Planning

6.

Mr. Andre / 24 yo

April 9th 2013

7.

Mr. Timotius / 32 yo

April 9th 2013

8.

Mrs. Thalha / 37 yo

April 9th 2013

1. Mr. M. Yusran/ 53 yo/ April 9th 2013 at 14.15

Chief Complain : Painful when urinate History : These complaints experienced during the one year. Patients are often control to the doctor and was diagnosed as BPH. When patients want surgery it was discovered that the patient was suspected Prostate Ca and do the biopsy. The patient was hospitalized for 1 month at Kapuas Hospital and referred to Ulin general hospital for further treatment. Current patient complaint is pain while urinating, urine comes out red and lumpy.

Physical Examination
Alert Vital sign :
BP = 100/60 mmHg PR = 88 bpm RR = 22 bpm T = 38,0C

Physical Examination
Head/Neck
Eyes : No anemic conjunctivae, icteric sclerae (-), Nose : No epistaxis Mouth : Wet mucosa Neck : Lymph nodes enlargement (-), JVP enhancement (-) I : Simmetric respiratory movement, no retraction P : Simmetric VF P : Sonor at all lung fields A : Simmetric VBS, no rhonchi, no wheezing I : Distention (-) A : Bowel sound (+) N P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) P : Tymphani

Chest

Abdomen

Extremities

Warm, no oedema, no parese

Urologic Status
CVA

I : mass (-/-), hematom (-/-) Pa : tenderness (-/-) Pe : pain (+/-)

Flank Area

I : mass (-/-), hematoma (-/-), Pa : tenderness (-/-)

SuprapubiC

I : mass (-), hematoma (-) Pa: tenderness (-)

Genitalia

OUE : bloody discharge (-) Penis: edema (-), hematoma (-) tenderness (-) Skrotum: mass (-), testis (+/+)

DRE
I : Haemorrhoid (-), laceration (-) P:
Sphincter ani muscle strong Smooth mucosa Ampulla wasnt collapse Mass (-) Tenderness (-) Prostat:
Touched, hard consistence Surface not flat Mediana sulci not palpable Upper pole not easy to touch Tenderness (-)

Handscon : feces (+), blood (-)

Laboratory Finding
Haematology Haemoglobin : 9.1 g/dl RBC : 3.28 WBC : 14.100 Hematocrit : 28.8 Platelet : 452.000 Chemistry BSR : 148 PT / APTT : 13.1 / 35.8 OT/ PT : 180 / 188 Ureum : 41 Creatinin : 0.9 Sodium : 138.5 Potassium : 3.9 Chloride : 99.1

Laboratory Finding
Urinalisa Color : Yellow BJ : 1000 Ph : 7.0 Protein-Albumin : 1+ Occult Blood : 3+ Urobilinogen : 0.2 Leukosit : 3+ Sedimen Leukosit : many Erythrosit : many Selinder : negative Epithel : 1+ Bactery : 1+ Crystal : negative

Clinical Picture

Clinical Picture

Urologi + USG Prostat

Working Diagnosis
Retensio Urine e.c. Susp. Ca. Prostat

Management
Co/ to Urology surgery: Aminofusin 30 tpm Ceftriaxon 2x1 Tramadol 2x1 Ranitidin 2x1

2. Mr. Khairudin/ 32 yo/ April 9th 2013 at 16.55

Chief Complain : History : 4 hours before admission, patient was inserted catheter urine because he was complained about cant urinate. 2 hours before admission, the patient was pull out the catheter. The patient complained about painful from genital and blood was out from his penis. Patient is patient with schizophrenia history and treated in Sambang Lihum hospital.

Physical Examination
Alert Vital sign :
BP = 110/70 mmHg PR = 80 bpm RR = 21 bpm T = 36,6C

Physical Examination
Head/Neck
Eyes : No anemic conjunctivae, icteric sclerae (-), Nose : No epistaxis Mouth : Wet mucosa Neck : Lymph nodes enlargement (-), JVP enhancement (-) I : Simmetric respiratory movement, no retraction P : Simmetric VF P : Sonor at all lung fields A : Simmetric VBS, no rhonchi, no wheezing I : Distention (-) A : Bowel sound (+) N P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) P : Tymphani

Chest

Abdomen

Extremities

Warm, no oedema, no parese

Urologic Status
CVA

I : mass (-/-), hematom (-/-) Pa : tenderness (-/-) Pe : pain (+/-)

Flank Area

I : mass (-/-), hematoma (-/-), Pa : tenderness (-/-)

SuprapubiC

I : mass (-), hematoma (-) Pa: tenderness (-)

Genitalia

OUE : bloody discharge (-) Penis: edema (-), hematoma (-) tenderness (-) Skrotum: mass (-), testis (+/+)

DRE
I : Haemorrhoid (-), laceration (-) P:
Sphincter ani muscle strong Smooth mucosa Ampulla wasnt collapse Mass (-) Tenderness (-) Prostat:
Touched, chewy consistence Nodul (-) Mediana sulci palpable Upper pole not easy to touch Tenderness (-)

Handscon : feces (+), blood (-)

Clinical Picture

Working Diagnosis
Susp. Laseration Uretra e.c DD Ruptur Uretra

Management
Co/ to Urology surgery : Discharge by permission

3. Mr. Sunaryo/ 60 yo/ April 9th 2013 at 17.10

Chief Complain : History : 1 days before admission, patient complained cant urinate. He was complained too about pain at the bilateral waist. The patient was inserted catheter urine in Marabahan Hospital then referred to Ulin General Hospital.

Physical Examination
Alert Vital sign :
BP = 130/80 mmHg PR = 84 bpm RR = 20 bpm T = 36,6C

Physical Examination
Head/Neck
Eyes : No anemic conjunctivae, icteric sclerae (-), Nose : No epistaxis Mouth : Wet mucosa Neck : Lymph nodes enlargement (-), JVP enhancement (-) I : Simmetric respiratory movement, no retraction P : Simmetric VF P : Sonor at all lung fields A : Simmetric VBS, no rhonchi, no wheezing I : Distention (-) A : Bowel sound (+) N P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) P : Tymphani

Chest

Abdomen

Extremities

Warm, no oedema, no parese

Urologic Status
CVA

I : mass (-/-), hematom (-/-) Pa : tenderness (-/-) Pe : pain (+/-)

Flank Area

I : mass (-/-), hematoma (-/-), Pa : tenderness (-/-)

SuprapubiC

I : mass (-), hematoma (-) Pa: tenderness (-)

Genitalia

OUE : bloody discharge (-) Penis: edema (-), hematoma (-) tenderness (-) Skrotum: mass (-), testis (+/+)

DRE
I : haemorrhoid (-), laceration (-) P:
Sphincter ani muscle strong Smooth mucosa Ampulla wasnt collapse Mass (-) Tenderness (-) Prostat:
Touched, chewy consistence Nodul (-) Mediana sulci palpable Upper pole not easy to touch Tenderness (-)

Handscon : feces (+), blood (-)

Laboratory Finding
Haematology Haemoglobin : 10.3 g/dl RBC : 3.67 WBC : 8000 Hematocrit : 32.5 Platelet : 190.000 Chemistry BSR : 148 PT / APTT : 11.8 / 27.2 OT / PT : 26 / 15 Ureum : 96 Creatinin : 1.3 Sodium : 136.3 Potassium : 3.0 Chloride : 100.4

Laboratory Finding
Urinalisa Color : Green BJ : 1.020 Ph : 5.5 Protein-Albumin : 1+ Occult Blood : 3+ Urobilinogen : 0.2 Leukosit : 2+ Sedimen Leukosit : 40-50 Erythrosit : 30-50 Selinder : negative Epithel : 1+ Bactery : negative Crystal : negative

Clinical Picture

Clinical Picture

X-Ray

Working Diagnosis
Retensi Urin e.c. Vesicolitiasis

Management
Co/ to Urology surgery: IVFD RL

4. Child Ali Yasir/ 8 yo / April 3th 2013 at 18.00 Chief Complain : Headache History : + 5 days before admission the patient had a traffic accident. Patient was riding the bicycle and hit by a motorcycle. History of unconsciousness (+). vomiting (-), bleeding nouse / ear / mouth (-/-/-). Headache (+). The patient was brought to Kapuas hospital, then reffered to Ulin general hospital.

Primary Survey
A
Clear, snoring (-), gurgling (-), c-spine control (+) Clear, RR=20 bpm, symmetric respiratory movement, symmetric VBS BP : 100/70 mmHg Pulse rate : 80 bpm, reguler, strong lifted, CRT < 2 sec. GCS E4V5M6, round and symmetric pupils diameter (2mm/2m), light reflexes (+/+), no paralysis

A M

P L
E

Ashphalt

Secondary survey
Head/Neck
Eye : anemic conjunctivae (-/-), icteric sclera (-/-) Mouth : Wet mucose Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-) Local status

Chest

I : symmetric respiratory movement, retraction (-) P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen
Extremities

I : wound (-), distension (-), hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

warm, edema (-), paralysis (-)

Clinical Picture

CT-Scan

Laboratory Finding
Haematology Haemoglobin : 10.2 g/dl RBC : 3.82 WBC : 8800 Hematocrit : 31.3 Platelet : 305.000 Chemistry BSR : 116 PT / APTT : 11.9 / 23.2 OT / PT : 20 / 9 Ureum : 33 Creatinin : 0.4 Sodium : 139.9 Potassium : 4.2 Chloride : 108.2

Working Diagnosis
EDH a/r Temporoparietal Dextra + SDH a/r Temporoparietal Sinistra

Management

5. Mrs. Ramsidah/ 51 yo/ April 9th 2013 at 18.35

Chief Complain : Pain at the right waist area History : 2 days before admission, patient experienced pain at the right waist area. The pain came intermittent, moderate pain (+), the pain came continuously. Nausea (-), vomiting (+), anorexia (-), fever (+). History of epigastric pain (-). Previous similar pain (-), previous abdominal surgery (-). Bowels (N), urinate (N). Because the complaint, patient was brought to Ulin General Hospital.

Physical Examination
Alert Vital sign :
BP = 170/100 mmHg PR = 80 bpm RR = 22 bpm T = 36,6C

Physical Examination
Head/Neck
Eyes : No anemic conjunctivae, icteric sclerae (-), Nose : No epistaxis Mouth : Wet mucosa Neck : Lymph nodes enlargement (-), JVP enhancement (-) I : Simmetric respiratory movement, no retraction P : Simmetric VF P : Sonor at all lung fields A : Simmetric VBS, no rhonchi, no wheezing I : Distention (-) A : Bowel sound (+) N P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) P : Tymphani

Chest

Abdomen

Extremities

Warm, no oedema, no parese

DRE
I : Haemorrhoid (-), laceration (-) P:
Sphincter ani muscle strong Smooth mucosa Ampulla wasnt collapse Mass (-) Tenderness (-) Handscon : feces (+), blood (-)

 Alvarado Score M0 A1 N2 T0 R0 E0 L S Psoas Sign (+)

Laboratory Finding
Haematology Haemoglobin : 11.9 g/dl RBC : 5.17 WBC : 15.600 Hematocrit : 38.3 Platelet : 248.000 Chemistry BSR : 91 PT / APTT : 14.6 / 29.3 OT / PT : 13 / 11 Ureum : 34 Creatinin : 1.4 Sodium : 141.0 Potassium : 3.7 Chloride : 110.8

Laboratory Finding
Urinalisa Color : Yellow BJ : 1.025 Ph : 6.0 Keton : 1+ Protein-Albumin : 2+ Occult Blood : 1+ Urobilinogen : 0.2 Leukosit : 2+ Sedimen Leukosit : 15-30 Erythrosit : 3-5 Selinder : negative Epithel : 2+ Bactery : negative Crystal : negative

Clinical Picture

X-Ray

Working Diagnosis
Nephrolytiasis Bilateral DD App

Management
Co/ to Urology surgery: IVFD RL 20 tpm

6. Mr. Hadarani/ 71 yo/ April 9th 2013 at 23.38

Chief Complain : History : KU : Nyeri pinggang kanan Pasien mengeluhkan nyeri pinggang sejak + 1 bulan SMRS. Nyeri dirasakan terus menerus tapi tidak menjalar dan tidak berkurang dengan perubahan posisi. Pasien juga mengeluhkan adanya benjolan sebesar bola tenis, keras dan terasa nyeri. Pasien juga mengeluhkan sulit kencing. Riwayat kencing batu (+) 6 th lalu,kencing darah (-).

Physical Examination
Alert Vital sign :
BP = mmHg PR = bpm RR = bpm T = C

Physical Examination
Head/Neck
Eyes : No anemic conjunctivae, icteric sclerae (-), Nose : No epistaxis Mouth : Wet mucosa Neck : Lymph nodes enlargement (-), JVP enhancement (-) I : Simmetric respiratory movement, no retraction P : Simmetric VF P : Sonor at all lung fields A : Simmetric VBS, no rhonchi, no wheezing I : Distention (-) A : Bowel sound (+) N P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-) P : Tymphani

Chest

Abdomen

Extremities

Warm, no oedema, no parese

Urologic Status
CVA

I : mass (-/-), hematom (-/-) Pa : tenderness (-/-) Pe : pain (+/-)

Flank Area

I : mass (-/-), hematoma (-/-), Pa : tenderness (-/-)

SuprapubiC

I : mass (-), hematoma (-) Pa: tenderness (-)

Genitalia

OUE : bloody discharge (-) Penis: edema (-), hematoma (-) tenderness (-) Skrotum: mass (-), testis (+/+)

DRE
I : Haemorrhoid (-), laceration (-) P:
Sphincter ani muscle strong Smooth mucosa Ampulla wasnt collapse Mass (-) Tenderness (-) Prostat:
Touched, hard consistence Surface not flat Mediana sulci not palpable Upper pole not easy to touch Tenderness (-)

Handscon : feces (+), blood (-)

Laboratory Finding
Haematology Haemoglobin : g/dl RBC : WBC : Hematocrit : Platelet : Chemistry BSR : PT / APTT : / OT/ PT : / Ureum : Creatinin : Sodium : Potassium : Chloride :

Laboratory Finding
Urinalisa Color : Yellow BJ : 1000 Ph : 7.0 Protein-Albumin : 1+ Occult Blood : 3+ Urobilinogen : 0.2 Leukosit : 3+ Sedimen Leukosit : many Erythrosit : many Selinder : negative Epithel : 1+ Bactery : 1+ Crystal : negative

Clinical Picture

X-Ray

Working Diagnosis

Management