EMERGENCY CASE REPORTS

Wenesday , February 5th , 2014

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Wenesday, February 5th 2014

Ambulation : Patient

Hospitalized : patients

Observation : patient
Operated : patient
Death : patient

Total : patients
No.1
Name : Mr. AS Sex : Male
Age : 15 years old No. Reg : 649767

Main complaint : Stab wound at right region of the neck

History taking : The condition had been apparent for 8 hour before the
patient admitted to the hospital. There were no history of
blood vomiting, bloody cough and dyspneu. Previous
medical care was carried out at Ibnu Sina hospital.
Mechanism of : The patient was walking on the street when suddenly he
injury was punctured by an arrow from unknown direction.
Sustained Injury : Right region of the neck
Symptom & sign : Pain
Examination : Physical examination, Laboratory examination, Chest X-
done Ray, CT scan Abdomen.
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR: 22x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP: 120/80 mmHg, PR: 84 x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal 2,5 mm/2,5 mm, Pupillary

reactivity to light was being brisk, no lateralized limb
weakness
E: T (ax): 36,1 oC
Secondary Survey
Regio Colli dextra :
I : Seen stabbed wound, edema (-),
hematoma (-), active bleeding (-), deformity (-)
P: Tenderness (+), Crepitating (-)
 Laboratory Result
WBC : 9,91 x 103 / L

RBC : 5.21 x 106 / L

HGB : 15,5 g/dL

HCT : 43,4 %

PLT : 282 x 103 / L

CT / BT : 800 / 300

Blood Sugar : 91 mg/dl

Ureum : 18 mg/dl

Creatinin : 0,89 mg/dl

SGOT/SGPT : 18 / 19 u/l
Cervical X-Ray
Chest X-ray
WORKING DIAGNOSE : Vulnus Ictum regio colli dextra

MANAGEMENT : O2
IVFD + resuscitation
Medicaments
Corpus Alienum Extraction
 No. 2
Name : Mrs. I Sex : Female
Age : 71 years No. Reg : 649881

Chief complaint : Pain at the whole abdomen wall

History taking : Suffered since 2 days before admitted to the
hospital. At the first, patient complained of sudden
abdominal pain at the center of abdomen. The pain
become worse and followed by bloating, nausea and
vomiting. And then he felt pain at the whole
abdomen and got fever. He was brought to primary
health care and referred to Wahidin Hospital .

Defecation : Never defecation and flatus since 2 days ago

Micturation : Less than normal.
 Physical Examination

General Conditions : Severe illness/ well nourished / conscious

Vital sign : BP : 140/90 mmHg

PR : 120 x/ minutes
RR : 22 x/ minutes
T : 38,5 C
PHYSICAL EXAMINATION

Abdomen
I : Distended, follow of breath motion, no bowel contour, no
bowel movements, no tumor mass.
A : Bowel sound (+), decreased
P : Tympani (+), Tapping pain (+)
P : Tenderness (+), Defans muscular (-)
Rectal Toucher

Sphincter ani was tight.

Mucous was smooth.
Ampula was empty.
No palpable tumor mass.

Gloves : feces (-), blood (-), slime (-)

Laboratory Result
WBC : 2,99 x 103 / L Natrium : 135 mmol/l

RBC : 5,43 x 106 / L Kalium : 4, 8 mmol/l

HGB : 15,8 g/dL Chloride : 108 mmol/l

HCT : 45,8 % HBsAg : Negatif

PLT : 365 x 103 / L Anti HCV : Negatif

CT / BT : 800 / 300 Uric acid : 9, 7

Blood Sugar : 134 mg/dl Albumin : 2, 6

Ureum : 41 mg/dl

Creatinin : 1,17 mg/dl

SGOT/SGPT : 20/15 u/l

 BNO 3
Position
WORKING DIAGNOSIS : Peritonitis generalisata et causa suspect perforation
gaster.

MANAGEMENT : O2
IVFD Resuscitation
apply NGT and urine catheter
Medicamentous
Report to senior digestive surgeon :
Advice : immediately laparatomy exploration
 Operating Procedure
Patient laid supine under GA
Desinfection & drapping Procedure
Midline incision 2 fingers under Proc. Xyphoideus until 2 fingers above SOP
Deepened until peritoneum, open peritoneum, seen gas erupts, and
yellow fluid from cavum peritoneum
Perform exploration , founded anthrum perforation size 1 x 1 cm
Refresh on perforation site, bring the tissue to pathology anatomy
apply NGT no.18 for gaster decompression and 16 for feeding, about 10
cm from the perforation spot
Close defect with primary suture and omentum flap
Wash peritoneal cavity with normal saline and close the wound layer by
layer and leaving 1 drain at douglas pouch
Operation finished
POST OPERATIVE : Peritonitis generalisata et causa antrum piloryc
DIAGNOSIS gastric perforation

PROGNOSIS : Good

FOLLOW UP : Vital Sign

Wound healing
Bowel function
No. 3
Name : Ch. E Sex : Male
Age : 15 years No. Reg : 649874

Chief complaint : Headache

History taking : This condition has been apparent for 12 hours before
admitted to the hospital due to head injury. History loss
of consciousness (+) nausea (+) vomiting (-).
Mechanism of : He was riding motorcycle, then a motorcycle struck him
injury from contrary, he slipped and fall down to the ground
with his head bumped to the ground

Injury sustain : Head, face

Symptom & sign : Headache
Examination : Physical examination, laboratory examination, head CT
scan
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR: 20x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP: 110/60 mmHg, PR: 88 x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal 2,5 mm/2,5 mm, Pupillary

reactivity to light was being brisk, no lateralized limb
weakness
E: T (ax): 37,0 CoC
Secondary Survey
Both orbital region :
I : Seen edema(+), hematoma(+), wound (-),
excoriation (-), active bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)
 Laboratory Result
WBC : 6, 8 x 103 / L

RBC : 4, 80 x 106 / L

HGB : 15, 0 g/dL

HCT : 16, 8 %

PLT : 167 x103/ L

CT / BT : 7 00 / 3 00

Blood Sugar : 137 mg/dl

Ureum : 46 mg/dl

Creatinin : 1, 1 mg/dl

GOT / GPT : 52 / 29 /L
Chest X-ray
Head CT Scan
WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)

MANAGEMENT : O2
Medicaments
Report to senior neurosurgeon
advice : Conservative

PROGNOSIS : Good

FOLLOW UP : Vital sign

 No. 5
Name : Baby Mrs. S Sex : Male
Age : 1 days No. Reg : 649794

Chief complaint : No Anal Canal

History taking : This condition had been apparent since 2 days before
admitted to ER, there was no history of vomiting with
greenish coloring liquid. There was no history of using
traditional drug during pregnancy.

Micturation : Normally
General Status
Moderate illness / well nourish / conscious

Vital Sign
PR : 130 x/mnt, strong, reguler,
RR : 32 x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 36,7 C
 Local Status
Anal Region
I : Seen no anal canal, anal dimple (+) skin color same with its vicinity
P : tenderness (-), tumor mass (-)
 Laboratory Result
WBC : 34.9 x 103 / L

RBC : 4.57 x 106 / L

HGB : 17.0 g/dL

HCT : 46.5%

PLT : 325 x103/ L

CT / BT : 900 / 300

Blood Sugar : 96 mg/dl

Ureum : 21 mg/dl

Creatinin : 0,3 mg/dl

GOT / GPT : 27/12 /L

Cross Table
WORKING DIAGNOSIS : MAR

MANAGEMENT : IVFD
Apply catheter
Apply NGT
Medicaments
Report to senior pediatric surgeon
advice : plan for anoplasty
 Operating procedure
Patient laid on prone position with elevated hip, under GA and caudal anesthesia
Disinfection and draping procedure
Identify anal dimple and muscle complex
Perform postero sagital incision, deepened until seen the tip of the rectum,
liberate from surrounding tissue
Resect distal of the rectum, seen meconium
Stich muscle complex, spicter interna and externa, to the skin, and the distal part
of the rectum
Control bleeding
Insert rectal tube (foley cathether 22) and fixate
Close the operation wound layer by layer
Operation is done
POST OPERATIVE : Post PSARP (posterosagital anoplasty e.c lower anal
DIAGNOSIS malformation

PROGNOSIS : Good

FOLLOW UP : Vital Sign

Wound healing
Bowel function
No. 6
Name : Mr. H Sex : Male
Age : 71 years old No. Reg : 649842

Chief complaint : Headache

History taking : This condition had been apparent for 30 minutes before
admitted to the hospital due to head injury. History loss
of consciousness (-) nausea (-) vomiting (-).
Mechanism of : He was riding his motorcycle than suddenly a car
injury passed by and bumped his motorcycle, then he loose
his balance, and fall down with his head hit the asphalt

Injury sustain : Head, face

Symptom & sign : Headache
Examination : Physical examination, laboratory examination, head CT
scan
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR :32 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP :140/ 80 mmHg, HR :100 x/minute, regular, adequate

D: GCS 15 (E4 M6 V5), pupil equal 2,5 /2,5 mm , LR +/+

E: T (ax) : 37,0 oC
Secondary Survey
Right temporal region :
I : Seen lacerated wound 3x0,5 cm, edema(+),
hematoma(+), wound (+), excoriation (+), active
bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)
 Laboratory Result
WBC : 6, 8 x 103 / L

RBC : 4, 80 x 106 / L

HGB : 15, 0 g/dL

HCT : 16, 8 %

PLT : 167 x103/ L

CT / BT : 7 00 / 3 00

Blood Sugar : 137 mg/dl

Ureum : 46 mg/dl

Creatinin : 1, 1 mg/dl

GOT / GPT : 52 / 29 /L
Thorax X-ray
Cervical lateral
Head CT Scan
CT 3D
WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
Depressed Fracture at right temporoparietal

MANAGEMENT : O2
Medicaments
Report to senior neurosurgery
advice : craniotomy

PROGNOSIS : Good

FOLLOW UP : Vital sign

THANK YOU