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Emergency Case

Report
TEMPLATE
Resident on Duty : dr. Zacky Junaedi
Chief Co-Assistant :
Inas

Team :
Dwiputra, Annandra, Dita, Detty, Puja,
Hafizh, Bima, Sanjaya
Minor Surgery :-

Digestive Surgery :1

Thorax Cardiovascular Surgery :-

Plastic Surgery :1

Urology Surgery :1

Neurosurgery :1

Pediatric Surgery :-

Oncology Surgery :-

Orthopaedy :-

Total :3
Patient List
No Identity Admissio Diagnosis Treatment
n to E.R.
2. Mr. Gusti April 24th Obstructive Jaundice VS Obs
Noor / 2015 at observation ec Susp CBD IVFD Asering
Cyst + Choleliihiasis + rehydrating
20.10
46yo/0-96 Moderate Cholangitis + Inj. Antibiotic
WITA Hyponatremia Inj. Analgesic
-79-57
Inj. H2Blocker

Complete blood
count
Thorax X ray

Consult to
Digestive
surgeon:
Antibiotic
Abdominal CT
SCAN
AFP & Gamma GT
Test
Rehydration and
hyponatremia
correction
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A R
LHospitalized
T
ECG
1. Mr. Gusti Noor / 46yo/0-96 -79-57
April 24th 2015 at 20.10 WITA
Chief Complain :
yellowish body
History :
Patient has been complaining that his body turned
yellowish since 2 weeks before admission. His complain
getting worse each day, even though he has never
experienced it before. The patient has been passing pale
stool on recent days. The patient also has been
complaining upper right quadrant abdominal pain since
last 2 weeks. Its getting worse with intermittent fever. The
patient has no history of alcohol consumption. Due to his
complaints, the patient went to Tanah Bumbu hospital for
medical help before got referred to Ulin Hospital for further
examination. History of DM nor HT denied.
C
L R T
ECG
Vital Sign
BP : 100/60 mmHg
PR : 108 bpm
RR : 22 tpm
T : 36,8oC
SpO2: 98%

C
A L R T
ECG
General Status

5 3 + +

5 3 + +
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A L R T
ECG
Rectal Touche
Anal sphincter tone (strong)
Mucous membrane sleek and smooth
Ampulla recti was not collapsed
Mass was not palpable
Tenderness (-)
BCR (+)
Faeces (+) yellow, Blood (-)
Clinical Pictures

C
A L R T
ECG
Local Status

a/r abdomen
I : distension (-), convex (+)
A : Bowel sound (+) normal
P : Liver/spleen/kidney not
palpable, mass not palpable,
Tenderness (+) a/r right upper
quadrant. Rebound pain (-)
Muscular Defense (-)
P : Tymphani

C
A L R T
ECG
Laboratory Result April 24th 2015
Items Result Normal Value Unit
Hemoglobine 13,0 14.00 - 18.00 g/dl

Leukocyte 23,7 4.0 10.5 thousand/ul

Eritrocyte 4,37 4.00 5.50 million/ul

Hematocrit 38,8 32.00 44.00 Vol%

Thrombocyte 130 150 450 Ribu/ul

RDW-CV 19,4 11.5 14.7 %

MCV 89,4 80.0 97.0 Fl

MCH 29,70 27.0 32.0 Pg

MCHC 33,5 32.0 38.0 %

C
A R T
ECG
Items Result Normal Value Unit

Gran% 81,5 50.0-70.0 %

Lymphosite% 7,1 25.0-40.0 %

MID% 11,4 4.00-11.00 million/ul

Gran# 19,30 2.50-7.00 Billion/ul

Limfosit # 1,7 1.25-4.0 Billion/ul

MID# 2,7 Billion/ul

HBs Ag (Cobas) Negative < 0,9 = non


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reactive
A R T
ECG
Items Result Normal Value Unit
GDS 90 <200 Mg/dL

Bilirubin Direct 13,52 0,2-1,2 Mg/dL

Bilirubin Indirect 9,64 0,00-0,40 Mg/dL

Bilirubin Total 23,16 0,2-0,6 Mg/dL

SGOT 100 0-46 U/l

SGPT 57 0-45 U/l

Protein total 6,0 6,2-8,0 mg/dL

Albumin 2,8 3,5-5,5 g/dL

Ureum 197 10-50 mg/dL

Creatinin 1,9 0,7-1,4 mg/dL

Natrium 121,7 135-146 mmol/L

Kalium 1,4 3,4-5,4 mmol/L

Chloride 76,6 95-100 mmol/L


C
A R ECG
Thorax X-Ray April 22th 2015 at
Tanah bumbu Hospital

C
A L ECG
T
USG April 22nd 2015 at Tanah
Bumbu Hospital

A L R ECG
Working Diagnosis
Obstructive Jaundice observation ec
Susp CBD Cyst + Choleliihiasis +
Moderate Cholangitis + Hyponatremia

C
A L R T
ECG
Management
VS Obs
IVFD Asering rehydrating
Inj. Antibiotic
Inj. Analgesic
Inj. H2Blocker
Complete blood count
Thorax X ray
Consult to Digestive surgeon:
Antibiotic
Abdominal CT SCAN
AFP & Gamma GT Test
Rehydration and hyponatremia correction
Hospitalized
C
A L R T
ECG