25-12-2016

IDENTITY

Name : Ny. LB
Age : 49 years old
Sex : Female
Address : SOE
Reffered from RSU Soe
 Anamnesis
Chief Complaint :

Decrease level of consciousness
MOI (heteroanamnesis)
Patient reffered from RSU Soe with severe head
injury. The mechanism of injury is unclear, patients
family said that patient didnt use helmet and got the
injury due to motocycle accident. After the accident
patient is unconscious and vomited blood once in
RSU Soe
 Primary Survey

A: clear
B : RR: 22 times in a minute
C : Blood preasure : 150/90 mmHg , Pulse: 88
times/minute, reguler.
D : GCS E1V2M4, pupil ishokor, 3mm/3mm
E : vulnus laceratum regio palpebra dextra
Vulnus laceratum regio maxilla dextra
Heatoma orbita dextra
 Secondary Survey

Head : vulnus laceratum regio palpebra dextra
Vulnus laceratum regio maxilla dextra
Heatoma orbita dextra
Eye : anemic (-/-), pupil isokor (+/+), icteric (-/-)
Ear : blood clot at left ear, ottorea (-/-)
Nose : blood clot (+/+), rhinnorea (-/-)
 Thorax

Inspection : chest expansion bilateral simetric,
pattern of respiration is abdominothoracal
Palpation : vocal fremitus R=D
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)
 Abdomen

Inspection : distended (-)
Auscultation : peristaltics (+) still normally
Palpation : tenderness pain (-), mass (-)
Percusion : timpany sound (+)
 Extremity

Look : normal
Feel : pain on the right upper leg (+), bruised (-)
Move
ROM : normal

FOTO minta di norman
 Laboratorium

CBC :
Hb 10,3 gr/dL
RBC 3,73 x 10^6/uL
Ht 30,6%
WBC 20,84 x 10^3/uL
Plt 109 x 10^3/uL
 Planning Diagnosis

Head CT Scan
Thorax x-ray
 Assessment

Severe Head Injury
vulnus laceratum regio palpebra dextra
Vulnus laceratum regio maxilla dextra
Heatoma orbita dextra
 Planning therapy

O2 6 lpm
IVFD RL 20 tpm
Inj. Piracetam 2x3 gr/iv
Manitol 100 ml/ 8 jam
Inj. Ceftriaxone 2x1 gr/iv
Pasang NGT dan DC
MLP 6x200 ml
Balance Cairan
 BIODATA

Name: CB
Age : 58 years old
Sex : Male
Address : Soe
Patient refferd from RSU Soe
 Anamnesis
Chief Complaint :

hard to urinate
NOI
patient reffered from RSU Soe with diagnose generalize peritonitis due
to vesica urinary rupture. Patient felt really hard to urinate and so
painful and blood drips from OUE. Patient also complaint about lower
abdominal pain, defecation 3x/day, vomit (-).
Patient has a history of abdominal surgery due to urinary stone in 2013
 Physical examination

GCS : E4V5M6
Vital sign
Blood pressure 120/80 mmHg
Pulse 104x/min
RR 21x/min
T 37,2 ^0C
Eye : anemis (-/-), pupils isokor (+/+), icteric (-
/-)
Ear : In normal limit
Nose : In normal limit
Throat : Normal
 Thorax

Within normal limit
 Abdomen

Inspection : distended (+)
Auscultation : intestinal sounds normal
Palpation : tenderness pain (+), pain on
palpation (+), mass in suprapubic region
and really painful
Percussion : timpany sound (+)
 Genitalia

Edema of scrotum and penis
 Extremity

Within normal limit
 Laboratorium
CBC :
Hb 9,6 gr/dL
RBC 3,20x10^6 /uL
Ht 27,6 %
WBC : 19,68x10^3/ul
Plt : 318
 Planning Diagnosis

USG Abdomen
 Assessment

Retensio urine ec. Susp. Ca buli-buli dd/ Ca genitalia
 Planning therapy

IVFD RL 20 tpm
Spooling until clear
Cotrimoxazole 2x2 tab
Paracetamol 3x1 tab


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