Scribd Logo
Upload

Welcome to Scribd!

  • 39 views

    HC Sol

    Uploaded by

    monyet65
    The document summarizes two emergency case reports from June 18-19, 2020. The first case was a 5-year-old girl admitted with hydrocephalus due to an infratentorial brain tumor. She received IV fluids, medications, and was consulted for urgent VP shunt placement and post-op PICU care. The second case was a 59-year-old woman with stage IV breast cancer, pleural effusion, anemia, and diabetes admitted for general weakness. She received IV fluids, medications, blood transfusion, and was consulted for oncology management including hospitalization. In total there were two patients seen in the emergency department over this period.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    HC Sol

    Uploaded by

    monyet65
    39 views30 pages
    The document summarizes two emergency case reports from June 18-19, 2020. The first case was a 5-year-old girl admitted with hydrocephalus due to an infratentorial brain tumor. She received IV fluids, medications, and was consulted for urgent VP shunt placement and post-op PICU care. The second case was a 59-year-old woman with stage IV breast cancer, pleural effusion, anemia, and diabetes admitted for general weakness. She received IV fluids, medications, blood transfusion, and was consulted for oncology management including hospitalization. In total there were two patients seen in the emergency department over this period.

    Original Description:

    MR

    Original Title

    HC SOL

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document summarizes two emergency case reports from June 18-19, 2020. The first case was a 5-year-old girl admitted with hydrocephalus due to an infratentorial brain tumor. She received IV fluids, medications, and was consulted for urgent VP shunt placement and post-op PICU care. The second case was a 59-year-old woman with stage IV breast cancer, pleural effusion, anemia, and diabetes admitted for general weakness. She received IV fluids, medications, blood transfusion, and was consulted for oncology management including hospitalization. In total there were two patients seen in the emergency department over this period.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    39 views30 pages

    HC Sol

    Uploaded by

    monyet65
    The document summarizes two emergency case reports from June 18-19, 2020. The first case was a 5-year-old girl admitted with hydrocephalus due to an infratentorial brain tumor. She received IV fluids, medications, and was consulted for urgent VP shunt placement and post-op PICU care. The second case was a 59-year-old woman with stage IV breast cancer, pleural effusion, anemia, and diabetes admitted for general weakness. She received IV fluids, medications, blood transfusion, and was consulted for oncology management including hospitalization. In total there were two patients seen in the emergency department over this period.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    You are on page 1of 30

    Emergency Case Report

    June 18th – 19th 2020

    Resident On Duty
    Riz Sanfebrian Adiatma

    DPJP ER:
    Dr. dr. Hery Poerwosusanta, Sp.B, Sp.BA, FICS
    Digestive Surgery :-

    Thoracic, Cardiac and Vascular Surgery :-

    Plastic, Reconstruction & Esthetic Surgery :-

    Urology : -

    Neuro Surgery : 1 Patient

    Pediatric Surgery :-

    Oncology Surgery : 1 Patient

    Orthopedic & Traumatology :-

    Total : 2 Patients
    Patient List
    No Identity Admission to ER Diagnosis Treatment

    1. Ch. Febby/5yo/MR June 18th 2020 at Hydrocephalus non Treatment in ER :


    1460300 10.00 am communicans e.c tumor IVFD D5 ½ NS 1300cc/24 hours
    Infratentorial Inj Ranitidin 2x25mg
    Inj Paracetamol 3x160mg
    Inj Ondancentron 2 mg if needed

    Consult Neurosurgery:
    Pro Cito VP shunt
    Post Op PICU
    Patient List
    No Identity Admission to ER Diagnosis Treatment

    2. Mrs. Rusdiana / 59 y.o/ June 18th 2020 at Ca Mammae dextra Treatment on ER


    RM 1432748 10.00 PM T4bN1M1 on kemoterapi + • IVFD RL loading 1000cc
    Effusi Pleura dextra Suspect • Maintenance with RL 1500cc/24
    Malignant + Anemia + DM hours
    type II • Inj. Levofloxacin 1x500mg
    • Inj. Omeprazol 1x40mg
    Karnofsky 60-70 % • Inj. Ondancentron 4 mg
    • Wound toilet with metronidazole
    powder
    Consul to oncologist:
    • Hospitalized
    • Transfusion with PRC 2 kolf/days
    until HB more than 10
    • Inj Leucogen 300mcg
    Ch. Febby/5yo/MR 1460300
    Admitted June 18th 2020 at 10.00 am

    Chief Complain : headache


    History taking : she complained of headache since 1 year before admitted. Headache was felt
    intermittently and progressive. Pain was throbbing and worsen when midnight. Headache is
    followed by dizziness, nausea, and vomiting. Patients also often fall if walking alone without
    apparent reason. She also felt his vision gradually worsen during 2 months ago. Now she can
    only see flashes of light. Abdominal pain (-), chest pain (-), tightness (-), stubborn (-), travel
    history out of town (-). Appetite was still good, patients during illness sleep more often than
    do activities, sleep sometimes not comfort.

    History of Past illness : -


    History of Family Illness: Malignancy (-)
    Vital Sign
    HR : 122 bpm (regular, strong)
    RR : 26 bpm
    Tax : 36,7 0C
    GCS : E4V5M6
    SpO2 : 100% without 02 Supply
    Weight : 16kg
    Physical Examination
    • Sclera icteric (-/-), pale conjungtiva (-/-), pupil equal 4 mm|4 mm, light reflex (+|+)
    Head minimal, head circumference 54 cm, venectation (+), sunset eye (+), Visus 1/∞,1/∞

    • I : symetric respiratory movement, retraction (-)


    Chest • P : sonor at all lung fields
    • A : symmetric VBS, rhonchi (-), wheezing (-)

    • I : distension (-)
    • A : bowel sound (+) normal
    Abdomen • P : soft, tenderness (-), defense muscular (-) tenderness (-) mass (-) ascites (-)
    • P : tympani at all region

    Extremities • warm extremities (+), edema (-), paresis (-), lateralization (-)
    Neurological State
    • GCS E4V5M6
    • Pupil unequal 4 mm|4 mm, minimal light reflex
    • Meningeal sign (-)
    • Babinsky reflex (+)
    • Lateralization (-)
    Clinical Picture
    Laboratory Finding
    Examination Result Normal Value
    Hemoglobin 13,8 12,00-16,00 g/dl
    Leukosit 3,6 4,0-10,5 ribu/ul
    Eritrosit 4,98 3,90-5,50 juta/ul
    Hematokrit 40 37,00-47,00 vol%
    Trombosit 326 150-450 ribu/ul
    RDW-CV 12,2 11,5-14,7 %
    MCV 80,3 80,0-97,0 fl
    MCH 27,7 27,0-32,0 pg
    MCHC 34,5 32,0- 38,0 %
    Neutrofil% 50,8
    Limfosit% 36,5
    Monosit% 8,8
    Neutrofil# 1,84
    Limfosit# 1,32
    Monosit% 0,32
    Laboratory Finding
    Examination Result Normal Value

    PT 11,7 9.9 -13.5 detik


    APTT 29 22.2- 37.0 detik
    INR 1,09
    Random Blood Glucose 115 <200.00 mg/dl
    SGOT 50 5-34 u/l
    SGPT 18 0-55 u/l
    Ureum 13 10-50 mg/dl
    Creatinin 0,47 0.6-1.2 mg/dl
    Natrium 136 135-146 mmol/L
    Kalium 4,2 3,4-5,4 mmol/l
    Chlorida 109 95-100 mmol/l
    Chest X-Ray from
    Ulin Hospital
    18/06/2020
    Non-contrast and contrast CT Scan
    24/04/2020 at Kotabaru Hospital
    Diagnosis
    hydrocephalus non comunicans e.c tumor Infratentorial
    Management
    Treatment in ER :
    • IVFD D5 ½ NS 1300cc/24 hours
    • Inj Ranitidin 2x25mg Consult Neurosurgery:
    • Inj Paracetamol 3x160mg • Pro Cito VP shunt
    • Inj Ondancentron 2 mg if needed • Post Op PICU
    Mrs. Rusdiana / 59 y.o/ RM 1432748
    Admitted at June 18th 2020 at 10.00 PM
    Chief Complain : general weakness
    History : Patient complained general weakness since 4 days before admitted. She felt his
    body weak and loss of appetite. She also nausea and vomite, she vomite his food, blood (-).
    She also complained pain at the right breast ulcer since. The pain was not accompanied by
    high fever and headache.
    Before that, she had lump at the right breast. Its size like a quaille egg, and became bigger
    like takraw ball during 6 months (TDT 22,5 days).
    She never felt shortness of breath, full in the abdomen, pain in the bone and headache. She
    only had decrease of appetite and lost of weight more than 10 kg in the last 3 months.
    Her first menstruation when she aged 14 years old, and her last menstruation 49 years old.
    She had 3 children, and never had abortus. Lactation history (+), contraception (-) KB
    History of chemoterapy : She already had chemoterapy 5 times.
    Family history : (-)
    Vital Sign
    • BP : 110/70 mmHg
    • HR : 110 bpm (regular, strong)
    • RR : 20 tpm
    • Tax : 36,80C
    • Karnofsky Score : 60-70%
    • SpO2 : 97%
    • VAS : 3/10
    Physical Examination
    • Head : Pale conjunctiva (+|+), light reflex (+|+), Edema palpebra (-/-), sclera
    icteric (-/-)
    Head • Mouth : Moist mucous membrane
    • Neck : enlargement of the lymph node (-)

    • I : symmetrical respiratory movement, retraction (-), venectation (-), ulkus and pus
    at mammae dx  see local state
    Chest • P : symmetrical VF
    • P : Sonor
    • A : SN vesikuler, no ronchi , no wheezing

    • I : distension (-), mass (-)


    • A : Bowel sound (+) normal
    Abdomen • P : soft, tenderness (-), liver / spleen / mass can’t be palpapted
    • P : timpani at all regio

    Extremities • warm, parese (-/-)


    Local Status
    a/r mammae dextra:
    • I : mass (+), ulcer (+), skin dimpling (-),
    active bleeding (-), necrotic tissue (+), pus
    (+), irregular margin, peau d orange (-)
    • P : mass (+), hard consistency, pain (+),
    immobile at right breast, irregular surface
    (+)
    a/r axilla dextra et sinistra
    • I : mass (+), irregular border, ulcus (-)
    • P : mass (+), conglomeration of lymph (-),
    immobile
    Clinical photos
    orax June, 18th 2020
    USG Abdomen 31 Juli 2019
    PA
    Laboratory Finding 11-4-2018
    Pemeriksaan Hasil Nilai Rujukan
    Hemoglobin 8,6 12,00-16,00 g/dl
    Leukosit 0,9 4,0-10,5 ribu/ul
    Eritrosit 3,22 3,90-5,50 juta/ul
    Hematokrit 24,6 37,00-47,00 vol%
    Trombosit 185 150-450 ribu/ul
    RDW-CV 13,7 11,5-14,7 %
    MCV 76,4 80,0-97,0 fl
    MCH 26,7 27,0-32,0 pg
    MCHC 35 32,0- 38,0 %
    Neutrofil% 19,8
    Limfosit% 28,6
    Monosit% 51,6
    Neutrofil# 0,18
    Limfosit# 0,26
    Monosit# 0,47
    Laboratory Finding
    Pemeriksaan Hasil Nilai Rujukan
    GDS 256 < 200 mg/dl
    SGOT 23 0-46 U/l
    SGPT 14 0-45 U/l
    Ureum 20 10-50 mg/dl
    Creatinin 0,63 0.6-1.2 mg/dl
    Natrium 136 135-146 mmol/L
    Kalium 4.5 3,4-5,4 mmol/l
    Chlorida 108 95-100 mmol/l
    Working Diagnosis
    Ca Mammae dextra T4bN1M1 on kemoterapi + Effusi Pleura dextra
    Suspect Malignant + Anemia + DM type II

    Karnofsky 60-70 %
    Treatment
    Treatment on ER • Wound toilet with metronidazole
    • IVFD RL loading 1000cc powder
    • Maintenance with RL 1500cc/24 Consul to oncologist:
    hours • Hospitalized
    • Inj. Levofloxacin 1x500mg • Transfusion with PRC 2 kolf/days
    • Inj. Omeprazol 1x40mg until HB more than 10
    • Inj. Ondancentron 4 mg • Inj Leucogen 300mcg

    You might also like