2 desember 13 dr alex
DESCRIPTION
dgdTRANSCRIPT
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Co-ass On Duty :Yulia, Daus, Mitha, Trias, Rahmat,
Hana,
Resident On Duty : Dr. Alex
EMERGENCY CASE REPORT
November 24th, 2013
Chief On Duty :Rohman
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– Minor Surgery = 0 Patients– Plastic Surgery = 0Patient– Orthopaedi = 0 Patient– Urology = 0 Patient– Pediatric Surgery = 1 Patient– Neurosurgery = 0 Patients– Oncology = 2 Patient– Thorax & Cardiovascular = 0 Patient– Digestive = 0 Patients
• Total New Patients = 2 Patients• All Patient will be reported
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No Identity Admission to
E.R.Diagnosis Treatment
1 Mrs. Suminah/ 43yo
Dec 2th 2013 at 15.00
Tumor a/r sternalis susp malignansi et
cause susp metastasis Ca
Ovarium + hipovolomic shock
IVFD RL rapidly 2 L : Maintenance Monitoring Vital SignCo. to Oncology:-improvement of the general state-over admissions to the obstetrics and gynecology department
2 Mrs. Nushasanah/ 41 yo
Dec 2th 2013 at 18.00
Mamae Tumor dextra suspect
malignancy T4cN3M1 + Pleural
effusion dextra+ Suspect metastasis
hepar
O2 3 l/mIVFD RLAntibioticLaboratory checkCo. to Oncology:HospitalizatedpCo. to Digestive surgery
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No Identity Admission to
E.R.Diagnosis Treatment
3 Boy. Rizqan Ridani
Dec 2th 2013 at 18.30
Blunt Abdomen Trauma susp intra
abdominal bleeding
O2 3 l/mIVFD RLAntibioticAnalgesicH2 BlockerLaboratory checkThorax photoBNOCo. to Pediatric Surgery:Consulent will visited
Discharge by request
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1. Mrs. Suminah/ 43yo/ 2 December 2013 at 15.00
Chief complaint : bleeding from the breastHistory : Patient was complained with bleeding
from the breast since 8 hours before admission, with estimated bleeding volume 500 cc. patients had been treated at Ulin Hospital and diagnose with susp dermoid cyst at cavum pelvis and Ca Mammae T4N3Mx and will control to obstetrics and gynecology department for radiotherapy or chemotherapy. Patient feel lethargic, and shortness of breath (+).
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Primary Survey
• Clear, snoring (-), gurgling (-), C-spine control (+) A
• Clear, RR=25 x/min, symmetric respiratory movement chest, right
VBS= left VBS, Rh(-/-), Wh (-/-) B
• TD: 60/30 mmHg, Pulse rate: 89 x/m regular but weak, C
• GCS E4V5M6, round and symmetric pupils diameter (3mm/3mm), D
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Secondary survey•Eye : anemic conjunctivae (+/+), icteric sclerae (-/-), •Mouth : wet mucous •Neck : increase of JVP (-), enlargement of limph node (-)
Head/Neck
• I : symmetric respiratory movement, retraction (-), look mass
• P : symmetric VF• P : sonor in all lung field• A :symmetric VBS, right VBS= lef t VBS Rh (-/-), Wh
(-/-)
Chest
• I : Flat, hematoma (-), wound (-)• A : normal bowel sound• P : H/L/M not palpable, Pressure pain (-), DM (-)• P : tympanic in all quadrants
Abdomen
• warm periphers (+), edeme (-), parese (-)Extremities
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Clinical Picture
Looks bandaged mass with active bleeding
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Abdomen CT-Scan+ Pelvis Result(Nov,14 2013)
Cystic Mass 17x15x22 from cavum pelvic with n calsification
mass appeared attached to the uterus and uterine urged to the right lateral suspect Dermoid cyst
HepatosplenomegalyHydronephrosis Grade 4 dextraOvarial cyst(Maligancy?)
Abdomen USG Result(Oct,24 2013)
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Laboratory Finding
Hb 9.1 g/dlLeu 12.8 thou/ulErit 3.67 mil/ulHt 28,4 vol%Tromb 392 ribu/ulGDS 109 mg/dlSGOT/PT 24/14Na/K/Cl 134,4/ 5,0/102,9Ureum /Creatinin : 36/1,0PT/ APTT: 10,2/26,3
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Working Diagnosis
Tumor a/r sternalis susp malignansi et cause susp metastasis Ca
Ovarium + hipovolomic shock
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Management
ResusitationIVFD RL rapidly 2 L : Maintenance Monitoring Vital SignCo. to Oncology:-improvement of the general state-over admissions to the obstetrics and
gynecology department
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2. Mrs. Nushasanah/ 41 yo/ 2 Desember 2013 at 18.00
Chief complaint : shortness of breathHistory : Patient was complained with shortness
of breathh since 1 weeks before admission, shortness of breath is not affected by the activities and not influenced by climate. initially sized of mass just like rambutan seed 2.5 years ago. Patient refused for surgery management. Patient menarche at 15 year old, and married at 22. first child its 18 year old. Patient was referred by Ratu zalecha Hospital to Ulin Hospital to got next treatment.
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Primary Survey
• Clear, snoring (-), gurgling (-), C-spine control (+) A
• Clear, RR=24 x/min, symmetric respiratory movement chest, right
VBS < left VBS, Rh(-/-), Wh (-/-) B
• TD: 110/70 mmHg, Pulse rate: 92 x/m regular. C
• GCS E4V5M6, round and symmetric pupils diameter (3mm/3mm), D
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Secondary survey•Eye : anemic conjunctivae (+/+), icteric sclerae (-/-), •Mouth : wet mucous •Neck : increase of JVP (-), enlargement of limph node (-)
Head/Neck
• I : symmetric respiratory movement, retraction (-), look mass
• P : symmetric VF• P : sonor in all lung field• A :symmetric VBS, right VBS= lef t VBS Rh (-/-), Wh
(-/-)
Chest
• I : Flat, hematoma (-), wound (-)• A : normal bowel sound• P : H/L/M not palpable, Pressure pain (-), DM (-)• P : tympanic in all quadrants
Abdomen
• warm periphers (+), edeme (-), parese (-)Extremities
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Clinical Picture
a/r thorax dextraLook mas 12x10x7 cm, irregular edge, fixed, edema(+) laseration(+), active bleeding (+)lymph nodes (+) axillary dextra, supraaclavicular dextra.
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Thorax Photo
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Post CTT Thorax Photo
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Abdomen USG
Kesan:HeparMetastase
pleural type metastase
Other in normal condition
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Laboratory Finding
Hb 10.4 g/dlLeu 6,7 thou/ulErit 3.79 mil/ulHt 32,3 vol%Tromb 219 ribu/ulGDS 139 mg/dlSGOT/PT 34/24Na/K/Cl 127.8/4.4 / 93.6Ureum /Creatinin : 11/o.2Albumin: 4.0
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Working Diagnosis
Mamae Tumor dextra suspect malignancy T4cN3M1 + Pleural
effusion dextra+ Suspect metastasis hepar
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Management
O2 3 l/mIVFD RLAntibioticLaboratory checkCo. to Oncology:
Co. to Digestive surgery
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3. Boy. Rizqan Ridani/ 13 yo/ 2 Dec 2013 at 18.30
Chief complaint : abdominal painHistory : : Patient had a traffic accident since 8 hours before
admission. Patient fall from motor cycle with chest bumped to asphalt. Patent was complained with abdominal pain, pain feel in upper abdomen. Head ache(-) nausea(-) vomit(-), history of unconscious (-) Bleeding from ear nose (-/-/-). Patient was referred by Tanjung Hospital to Ulin Hospital to got next treatment.
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Primary Survey
• Clear, snoring (-), gurgling (-), C-spine control (+) A
• Clear, RR=32 x/min, symmetric respiratory movement chest, right
VBS= left VBS, Rh(-/-), Wh (-/-) B
• TD: 90/60 mmHg, Pulse rate: 92 x/m regularC
• GCS E4V5M6, round and symmetric pupils diameter (3mm/3mm), D
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A -
M Ceftriaxone, Ranitidin, antrain
P -
L 10 hours before admission
E On the road
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Secondary survey•Eye : anemic conjunctivae (-/-), icteric sclerae (-/-), looks bruised around the eyes•Mouth : wet mucous •Neck : increase of JVP (-), enlargement of limph node (-)
Head/Neck
• I : symmetric respiratory movement, retraction (-), • P : symmetric VF• P : sonor in all lung field• A :symmetric VBS, right VBS= lef t VBS Rh (-/-), Wh
(-/-)
Chest
• I : Flat, hematoma (+) a/r epigastrica, wound (-)• A : normal bowel sound• P : H/L/M not palpable, Pressure pain (+), DM (-)• P : tympanic in
Abdomen
• warm periphers (+), edeme (-), parese (-)Extremities
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Clinical Picture
a/r thorax et epigastricaLook laceration wound
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X-Ray
recline stand
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Laboratory Finding
Hb 11.2 g/dlLeu 19.6thou/ulErit 3.99 mill/ulHt 32.9 vol%Tromb 294 thou/ulGDS 168 mg/dlSGOT/PT 488/25Na/K/Cl 127.8/ 4.4 / 93.6Ureum /Creatinin : 11/0.2PT/ APTT: 11.8/23.4
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Working Diagnosis
Blunt Abdomen Trauma susp intra abdominal bleeding
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Management
O2 3 l/mIVFD RLAntibioticAnalgesicH2 BlockerLaboratory checkThorax photoBNOCo. to Pediatric Surgery:Consulent will visited