Emergency Reportokt 20-21th 2015

Resident on duty:dr. deni budinata

dr. Yan aditya

Chief: BernadethSally, nia , laila, panji, rifqy,

panji,

General Surgery : -

Digestive Surgery : -

Thorax Cardiovascular Surgery : -

Plastic Surgery : -

Urology Surgery : -

Neuro Surgery : -

Pediatric Surgery : -

Oncology Surgery : 2

Orthopaedy : -

Total : 2

Patient ListNo Identity Admission to ER Diagnose Treatment

1. Mrs. Alsyaturidma / 43 y.o/ 1186508

Oct 5 th , 2015 Left breast Tumor suspected maligna

T4CN1M1 (contralateral) + hiponatremi Karnofski 60

VS obs 02 IVFD NSAnalgetic H2 blockerComplete blood count

Consulted to oncology surgery:Hospitalized Coagulant Breast USG FNAB +biopsi

Patient ListNo Identity Admission to ER Diagnose Treatment

2. Mr. husairin / 44 y.o/ 1186914

Oct 5 th , 2015 Dysphagia due to susp laryng tumor Karnofski

60

VS obs IVFD NSAnalgetic H2 blockerComplete blood count Thorax x ray

Consulted to oncology surgery: HospitalizedATB Consult ENT from ward

1. Mrs. Alsyaturidma / 43 y.o/ 1186508

Chief Complain:Mass at right breast History of Current Disease:Since one year before admission, patient complain mass at her right breast when it first known the mass as big as marble, she didn’t feel pain at her breast and the mass getting bigger until as big as apple now , the mass broke up two days ago with bleeding and pus. No history of fever, no history of trauma at her breast patient get menarche at 12 yo. And menstruation cycle was normal. and patient still get menstruation, History of breast feeding (+), she was delivered her first child at 20 yo. No familial history of cancer, history of hormonal contraception (+). Because of her complain patient was brought by her family to oncologist surgeon and referred to ULIN general hospital to get treatment., patient need to be help in some of her daily activities.

• Conciousness : compos mentis • Vital sign :

– BP = 100/70 mmHg– PR = 90 bpm– RR = 24 bpm– T = 36,7ºC

Physical Examination

General Status• Eyes : anemic conjunctiva, (+) icteric sclera (-)• Mouth : Wet mucous• Neck : Lymph nodes enlargement (-), JVP enhancement (-).

Head/Neck

• I : Symmetric respiratory movement,no retraction, malignancy ulcers (+) • P : Symmetric VF• P : Sonor at all lung fields• A : symmetric VBS, rhonchi (-), no wheezing

Chest

• I : Wound (-), distension (-),• A : Bowel sound (+) normal• P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-)• P : Tymphani

Abdomen

• Warm extremities, parese (-), edema (-)Extremities

Clinical Picture

• Breast tumor 15 cm diameter, peu d orange (+), malignancy ulcer (+)

• hard consistency, fixed to chest wall

Laboratory (06-02-2015)Examination Result Normal value

hemoglobin 10.2 11.00-16.00 g/dl

Leucosit 8.1 4.0-10.5 Ribu/ul

eritrosit 3.51 4.50-6.00 juta/ul

hematocrit 31.3 42.00-52.00 Vol%

trombocit 359 150-450 Ribu/ul

Random Blood Glucose

159 <200 Mg/dL

SGOT 91 0-46 U/I

SGPT 35 0-45 U/I

Urea 38 10-50 Mg/dL

Creatinine 1.2 0.7-1.4 Mg/dL

Na 128.7 135-146 Mmol/l

K 3.6 3.4-5.4 Mmol/l

Cl 98.8 95-100 Mmol/l

Thorax x ray

Working Diagnosis

Left breast Tumor suspected maligna T4CN1M1 (contra lateral) + hiponatremi Karnofski 60

Management

VS obs 02 IVFD NSAnalgetic H2 blockerComplete blood count

Consulted to oncology surgery:Hospitalized Coagulant Breast USG FNAB +biopsi

2. Mr. husairin / 44 y.o/ 1186914

Chief Complain:Dysphagia History of Current Disease:Since one year before admission, patient complain dysphagia and unable to speak , before unable to speak patient complain hoarness.no history of bloody sputum Since last week patient cant swallow any food. No history of fever, no history of trauma History of smoking (+) for 20 years. No familial history of cancer. patient loss his body weight in last six month.no history of biopsy before, no history of laryngoscopy before. Because of his complain patient was brought by her family to Kotabaru hospital and referred to ULIN general hospital to get further treatment patient need to be help in mostly of his daily activities.

• Conciousness : compos mentis • Vital sign :

– BP = 110/70 mmHg– PR = 80 bpm– RR = 28 tpm– T = 36,7ºC

Physical Examination

General Status• Eyes : anemic conjunctiva, (-) icteric sclera (-)• Mouth : Wet mucous• Neck : Lymph nodes enlargement (-), JVP enhancement (-).

Head/Neck

• I : Symmetric respiratory movement,no retraction, • P : Symmetric VF• P : Sonor at all lung fields• A : symmetric VBS, rhonchi (-), no wheezing

Chest

• I : Wound (-), distension (-),• A : Bowel sound (+) normal• P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (-)• P : Tymphani

Abdomen

• Warm extremities, parese (-), edema (-)Extremities

Clinical Picture

Laboratory (06-02-2015)Examination Result Normal value

hemoglobin 11,8 11.00-16.00 g/dl

Leucosit 16,8 4.0-10.5 Ribu/ul

eritrosit 4,38 4.50-6.00 juta/ul

hematocrit 31.3 42.00-52.00 Vol%

trombocit 359 150-450 Ribu/ul

Random Blood Glucose

153 <200 Mg/dL

SGOT 32 0-46 U/I

SGPT 35 0-45 U/I

Urea 38 10-50 Mg/dL

Creatinine 1.2 0.7-1.4 Mg/dL

Na 125.7 135-146 Mmol/l

K 3.5 3.4-5.4 Mmol/l

Cl 95.1 95-100 Mmol/l

Thorax x ray

Working Diagnosis

Dysphagia due to susp laryng tumor Karnofski 60

Management

VS obs IVFD NSAnalgetic H2 blockerComplete blood count Thorax x ray

Consulted to oncology surgery: HospitalizedATB Consult ENT from ward