Emergency Case Report

June 27th-28th 2013

Resident on duty : dr.

Yohannes F.
Chief co assistant : M.
Rizky F.
Team :
Ririn, Widia, Susandy, Iwan, Nurprianto, Hermawan, Amalia, Wiresa
Minor Surgery :-

Digestive Surgery :1

Thorax Cardiovascular Surgery : -

Plastic Surgery :-

Urology Surgery :-

Neurosurgery :3

Pediatric Surgery :-

Oncology Surgery :-

Orthopaedi :-

Total :4
No. Identity Admission Diagnosis Treatment /
to E.R. Planning

4. An. Supe/ 9 June 27th, Mild Head Injury + Debridemant

y.o 2013 at Excoriated wound at Wound toilet
23.30 frontal and periorbita Observation 6
hours
 Patients List
No. Identity Admission Diagnosis Treatment /
to E.R. Planning

1. Mr. Sakkar/ June 27th, Mild Head Injury + Hospitalizatio

17 y.o 2013 at pneumothorax dextra d.t n
21.00 thorax blunt trauma + Chest tube
intraabdominal bleeding dt Antibiotics
blunt trauma Anlgetics
H2 blocker
Stabilisation
in ICU
2. Mr. Sentikin/ June 27th, Severe Head Injury + Oxygenation
21 y.o 2013 at Shock Hypovolemic grade Head up 30
23.15 III unstable + suspect Fluid
intrabdomen bleeding d.t resuscitation
blunt trauma Catetherisatio
n
3. Ms. Aspiah/ June 27th, Mild Head Injury + Debridemant
14 y.o 2013 at Excoriated wound at right Wound toilet
1. Ny. Gusti Aliani ( 28 y.o) / / 1055080

Chief complaint : Pain at whole stomach regio

History : Pasien mengeluh nyeri seluruh
perut 18 jam sebelum masuk rumah sakit.
Nyeri dirasakan tiba-tibs dan terus-menerus.
Mual/muntah (-/-), BAK tidak ada kelainan.
Physical examination
Alert
Vital Sign
BP: 120/80 mmHg
HR: 85 x/minutes
RR: 20 x/minutes
T: 36,8 C
Head/Neck
Clinical Picture
Working Diagnosis
Mild Head Injury + pneumothorax dextra d.t
thorax blunt trauma + intraabdominal
bleeding d.t blunt trauma
1. Ny. Gusti Aliani ( 28 y.o) / / 1055080

Chief complaint : Nyeri seluruh perut

History : Pasien mengeluh nyeri seluruh
perut 18 jam sebelum masuk rumah sakit.
Nyeri dirasakan tiba-tibs dan terus-menerus.
Mual/muntah (-/-), BAK tidak ada kelainan.
Management
Hospitalization
Chest tube
Antibiotics
Anlgetics
H2 bloker
Stabilisation in ICU