EMERGENCY CASE REPORTS

Monday , February 17th , 2014

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Monday, February 17th 2014

Ambulation : 5 Patient

Hospitalized : 4 patients

Observation : 1 patient
Operated : - patient
Death : - patient

Total : 5 patients
No.
Name : Ch. MA Sex : Male
Age : 10 years old No. Reg : 651519

Main complaint : Decrease of conciousness

History taking : The condition had been apparent for 4 hours before the
patient taken to the hospital due to traffic accident .
There were events of vomtting and unconsciousness.
Previous medical care was carried out at Jeneponto
Hospital.
Mechanism of : The patient was playing near the road, when suddenly
injury motorcycle from his opposite direction strucked him. He
was thrown and with his head landed first onto the road.

Sustained Injury : Head

Symptom & sign : Headache
Examination : Physical examination, Head CT Scan,
done
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR: 24x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP: 110/60 mmHg, PR: 96x/minute, regular, adequate

D: GCS 9 (E2M5V2), pupil unequal 4 mm/2,5 mm, Light

Reflex +/+
E: T (ax): 36,5 oC
Secondary Survey

Occipital region :
I : Seen lacerated wound 3x1 cm, edema (+),
active bleeding (-)
P : Crepitation (-)
 Laboratory Result
WBC : 18,11 x 103 / L

RBC : 4,07 x 106 / L

HGB : 12,5 g/dL

HCT : 34,1 %

PLT : 277x 103/ L

CT / BT : 800 /200

Blood Sugar : 115 mg/dl

Ureum : 25 mg/dl

Creatinin : 0,7 mg/dl

GOT / GPT : 59/29 /L

Head CT scan
WORKING DIAGNOSIS : - Moderate head injury GCS 9 (E2M5V2)
- Linier fractured at right temporal bone
- EDH at Right Temporal Region

MANAGEMENT : O2
Apply IVFD
Medicaments
Consult to senior Neuro Surgeon
Advice: Proceed Immediate Craniectomy
 Operation Procedure
Patient laid supine under GA
Disinfection and drapping procedure
Perform question mark incision, deepen until pericranium
Seen linier fracture at right temporal region
Perform 1 burrhole, continued craniectomy with craniotom,
seen hematoma epidural 30 cc
Evacuate hematom ,
bleeding control, hanging dura
Close wound layer by layer with 1 vacuum drain
Operation finished
POST OP DIAGNOSIS : - Moderate Head Injury GCS 9 (E2M5V2)
- EDH at Right Temporal Region

PROGNOSIS : Good

FOLLOW UP : Vital sign, GCS

No. 1
Name : Mr. T Sex : Male
Age : 37 years No. Reg : 651489

Chief complaint : Decrease of consciousness

History taking : This condition has been apparent for 8 hours before
admitted to the hospital due to traffic accident. History
loss of consciousness (+) nausea (-) vomiting (-).
Mechanism of : He was riding motorcycle, suddenly he got struck by
injury another motorcycle from his opposite direction, he
slipped and then fell down with his head bumped to the
ground first
Injury sustain : Head, face
Symptom & sign : Headache
Examination : Physical examination, laboratory examination, head CT
scan
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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

abdominal type

C: BP :110/ 60 mmHg, HR :68 x/minute, regular, adequate

D: GCS 12 (E3 M5 V4), pupil equal 2,5 /2,5 mm , LR +/+

E: T (ax) : 37,0 oC
Secondary Survey
Left parietal region :
I : Seen edema(+), hematoma(-), wound (-),
deformity (-)
P : Crepitation (-)
 Laboratory Result
WBC : 16, 8 x 103 / L

RBC : 4,05 x 106 / L

HGB : 12,5 g/dL

HCT : 37,7%

PLT : 204 x103/ L

CT / BT : 8 00 / 2 30

Blood Sugar : 152 mg/dl

Ureum : 42 mg/dl

Creatinin : 0.8 mg/dl

GOT / GPT : 100 / 53 /L

Cervical X-Ray
Head CT Scan
WORKING DIAGNOSIS : Moderate head injury GCS 12 (E3M5V4)
ICH at right temporal region

MANAGEMENT : O2
Medicaments
Report to senior neurosurgeon
advice : conservative

PROGNOSIS : Good

FOLLOW UP : Vital sign

No. 2
Name : Mr. L Sex : Male
Age : 17 years No. Reg : 651445

Chief complaint : Headache

History taking : This condition has been apparent for 22 hours before
admitted to the hospital due to traffic accident. History
loss of consciousness (+) nausea (+) vomiting (-).
Mechanism of : He was riding motorcycle in high speed, then he loose
injury his balance and fell down with his head and face,
bumped to the asphalt first.

Injury sustain : Head, face

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

B: RR :24 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP :110/ 60 mmHg, HR :68 x/minute, regular, adequate

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

E: T (ax) : 37,1 oC
Secondary Survey
Both orbital region :
I : Seen edema(+), hematoma(+), in both superior
palpebrae, wound (-), excoriation (-), active
bleeding(-), deformity (-)
P : Crepitation (-)

Mandibular region :
I : Seen deformity (+) edema (+) and hematome (+) ,
wound (-), excoriation (-), active bleeding (-)
P : Crepitation (+)
 Laboratory Result
WBC : 16,3x 103 / L

RBC : 2,88 x 106 / L

HGB : 8,9 g/dL

HCT : 26,8 %

PLT : 168 x103/ L

CT / BT : 8 00 / 2 00

Blood Sugar : 105 mg/dl

Ureum : 46 mg/dl

Creatinin : 0,7 mg/dl

GOT / GPT : 275/ 499 /L

Head CT Scan
WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
Closed segmental fracture of mandibular

MANAGEMENT : O2
Medicaments
Report to senior plastic surgery
advice : elective operation

PROGNOSIS : Good

FOLLOW UP : Vital sign

No. 3
Name : Mr. K Sex : Male
Age : 28 years No. Reg : 651494

Chief complaint : Decrease of consciousness

History taking : This condition has been apparent for 24 hours before
admitted to the hospital due to traffic accident. History
loss of consciousness (+) nausea (-) vomiting (-).
Mechanism of : He was riding motorcycle, then he loose his balance and
injury fall down with his head bumped to the asphalt first

Injury sustain : Head, face

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

B: RR :24 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP :120/ 70 mmHg, HR :72 x/minute, regular, adequate

D: GCS 12 (E3 M5 V4), pupil equal 2,5 /2,5 mm , LR +/+

E: T (ax) : 37,0 oC
Secondary Survey
Right parietal region :
I : Seen stiched wound 3x1 cm, edema(+),
hematoma(-), wound (-), excoriation (-), active
bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)
 Laboratory Result
WBC : 16,8 x 103 / L

RBC : 3, 80 x 106 / L

HGB : 12,5 g/dL

HCT : 39,7 %

PLT : 204 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
Head CT Scan
WORKING DIAGNOSIS : Moderate head injury GCS 12 (E3M5V4)
Epidural hematoma at right temporoparietal
region
Subdural hematome at left parietal region
MANAGEMENT : O2
Medicaments
Report to senior neurosurgeon
advice : conservative

PROGNOSIS : Good

FOLLOW UP : Vital sign

No. 4
Name : Mr. R Sex : Male
Age : 55 years No. Reg : 545265

Chief complaint : Headache

History taking : This condition has been apparent for 2 hours before
admitted to the hospital due to accident. History loss of
consciousness (-) nausea (-) vomiting (-).
Mechanism of : He was sitting near the wall then he knocked the wall,
injury and the wall fall on him and hit most of his body

Injury sustain : Head, face

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

B: RR :46 x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP :110/ 60 mmHg, HR :68 x/minute, regular, adequate

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

E: T (ax) : 37,1 oC
Secondary Survey
Both orbital region :
I : Seen edema(+), hematoma(+), in both superior
palpebrae, wound (-), excoriation (-), active
bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)

Right parietal region :

I : Seen edema (+), hematome (+), bleeding (+)
excoriation (+) in right cheek, deformity (-)
P: Tenderness (+), Crepitating (-)
 Laboratory Result
WBC : 13,0 x 103 / L

RBC : 4,76 x 106 / L

HGB : 10,8 g/dL

HCT : 33,6%

PLT : 167 x103/ L

Blood Sugar : 146 mg/dl

Ureum : 38 mg/dl

Creatinin : 1, 00 mg/dl

GOT / GPT : 34/ 32 /L

SKULL X-RAY
Head CT Scan
WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
Dentoalveolar fracture
Multiple excoriation

MANAGEMENT : O2
Medicaments
Report to senior neurosurgeon
advice : conservative
Report to senior plastic surgeon
Advice : plan for elective surgery
PROGNOSIS : Good

FOLLOW UP : Vital sign

No.5
Name : Mrs. S Sex : female
Age : 30 years old No. Reg : 651540

Chief complaint : Wound on upper lips and bloody nose

History Taking : The condition had been apparent for 30 minutes before
the patient admitted to the hospital due to traffic
accident, there were pain, and and bloody nose.
Mechanism of : She was riding motorcyle when suddenly bus in front of
injury him stooped, then she hit the bus and bumped her face
to the bus and asphalt
Sustained injury : Lips, nose
Symptom & sign : Wound
Examination : Physical examination
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR : 16x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP : 110/60 mmHg, PR : 80x/minute, regular, adequate

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

+/+, all motoric muscle function are normal
E: T (ax) : 37,1 oC
Secondary Survey
Regio dorsum pedis dextra :
I : Seen lacerated wound size 1x0,5 cm. Edema
(+) in upper lips
P : Tenderness (+), Crepitation (-)
WORKING DIAGNOSIS : - Vulnus laceratum at upper lips
- Epistaxis

MANAGEMENT : Medicament
Proceed Wound Care
Patient discharge
THANK YOU