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EMERGENCY CASE REPORTS

Saturday, March 1st , 2014


SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Saturday, March 1st 2014

Ambulation : Patient

Hospitalized : patients

Observation : patient
Operated : patient
Death : patient

Total : patients
No.
Name : Mr. U Sex : Male
Age : 21 years No. Reg : 653015

Chief complaint : Abdominal Pain


History taking : Suffered since hours before admitted to the
hospital. Initially he felt pain at the right upper
abdomen. Then spread throughout the abdomen.
Followed by nausea, vomiting and no fever. Pain
increased when he moving and coughing.

Defecation : Normal
Micturated : Normal
Physical Examination

General Conditions:
Moderate illness / well nourish / conscious

Vital sign:
BP : 120/70 mmHg
PR : 76 x/mnt, regular, adequate.
RR : 21 x/mnt.
T(Ax) : 37 °C
PHYSICAL EXAMINATION
Abdomen
I : Seen convex, follow breath motion, no bowel contour, no bowel
motion, no tumor mass.

A : Decreased of Bowel sound

P : Tenderness at whole abdomen ,Muscular defans (+) at whole abdomen

P : Tympani
Rectal Toucher

 Sphincter ani was tight,


 Mucous was smooth,
 Ampula filled with faeces,
 No palpable mass,
 No pain at palpation

Gloves : Faeces (+), blood (-), slime (-)


Laboratory Result
WBC : 17,9 x 103 / μL Na : 126

RBC : 5,09 x 106 / μL K : 3,4

HGB : 13,4 g/dL Cl : 97

HCT : 40,1 % HbsAg Non reactive

PLT : 302x 103 / μL Anti HCV Non reactive

CT / BT : 2’30” / 7’00” Albumin 3,8

Blood Sugar : 101 mg/dl

Ureum : 43 mg/dl

Creatinin : 0,6 mg/dl

SGOT/SGPT : 12/11 u/l


Thorax X-ray
BNO X - Ray
BNO X-Ray
WORKING DIAGNOSIS : •Intestinal obstruction e.c suspicous volvulus
•SIRS

MANAGEMENT :  IVFD
 Apply NGT
 Apply Foley Catheter urine
 Medicaments
 Report to Senior Digestive Surgeon
advice : Immediate Laparotomy
OPERATION PROCEDURE
• Patient laid supine under GA
• Disinfection and drapping procedure
• Performed midline deepen layer by layer, until
peritoneum
• Identify, seen dilatation on every part of the bowel
• Seen volvulus ileum and multiple band, 50cm on distal
part and 90 cm proximal part from the ileocaecal valve
• Seen ischemic part of the ileum, resection of the ileum is
performed
• Decompression of the of the dilatated ileum
• Perform end-to-end anostomosis
• Control the bleeding and rinse cavum abdomen
• Close wound layer by layer with 1 drain
• Done
POST OP DIAGNOSIS : •Intestinal obstruction e.c volvulus
•multiple band
•SIRS
PROGNOSIS :  Good

FOLLOW UP :  Vital Sign


 Abdominal Pain
No.
Name : Mr.Ch.A Sex : Male
Age : 6 years No. Reg : 653018

Chief complaint : Lump at scrotum

History taking : This condition had been apparent since 1 year ago. The
lump would be bigger when he was standing and would
be smaller when he lied. The symptom aggravates when
before while his abdomen distended. The lump along
without pain and can not reduce again.
Micturation : Normally

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

Vital Sign
BP : 100/80 mmHg
PR : 84x/mnt, strong, reguler,
RR : 18x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 36,8°C
Local Status
Abdominal
I : Flat, follow breath motion, skin color same with vicinity, bowel contour
(-), bowel motion (-)
A : Peristaltic (+) sound normal
P : Tenderness (-) ,Tumor mass (-)
P : Tympani
Local Status
Scrotal region region
I : Seen ovale lump from craniolateral to caudomedial until scrotum,skin
color reddish than vicinity
P : Palpable lump at right scrotum, soft consistency , tendernes(+),
palpable 2 testis normally
A : Peristaltic (-)
Digital Rectal Examination
Sphincter tone was tight
Mucous was smooth
Ampulla collaps
Handscoen: blood (-), feces (-), slime (-)
BNO X-Ray
Laboratory Result
WBC : 15,7x 103 / μL

RBC : 4,13x 106 / μL

HGB : 11,1 g/dL

HCT : 33%

PLT : 334x103/ μL

PT/APTT : 8,00” / 3,00”

Blood Sugar : 83 mg/dl

Ureum : 16 mg/dl

Creatinin : 0,3mg/dl
40/ 11 μ/L
GOT / GPT :
WORKING DIAGNOSIS : •Hernia Inguinalis Dextra Incarserated
•Hidrocele dextra
MANAGEMENT : • IVFD
• Medicaments
• Report to senior Pediatric surgeon
advice : Herniotomy and Hernioraphy
Operation Procedure
• Patient laid in supine position under GA
• Draping and disinfection procedure
• Tranversal incision10 cm under umbilicus, deepen until peritoneum
• Open peritoneum, seen yellowish fluid, like ascites, about 500cc,
dilate tranversum colon
• Identify intraperitoneal organ, seen herniation of ileum to anulus
inguinalis dextra. Liberate hernia sac that still viable
• Perform hidrokelektomi peringuinal, by making incision of 3 cm
above inguinal ligament, deepen until hernia sac
• Ligate hernia sac as proximal as possible
• Control bleeding, apply drain in douglas pouch
• Close operation wound layer by layer
• Operation is done
POST OP DIAGNOSIS : •Hernia Inguinalis Dextra Incarserated
•Hidrocele dextra ascites

PROGNOSIS : Fair

FOLLOW UP : Vital Sign


Acute Abdominal Sign
No.
Name : Ms N Sex : Female
Age : 13 years old No. Reg : 653034

Main complaint : Decrease of conciousness


Condition : The condition had been apparent for 5 hours due to
traffic accident. There were events of lucid for 3 hours
after the accident, and lost of conciousness for the last 2
hours.
Mechanism of : The patient was walking home after school then a
injury motorcycle hit her from her side

Sustained Injury : Head


Symptom & sign : Headache
Examination : Physical examination, Head CT Scan, Skull AP/Lat,
done Thorax X-ray
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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


abdominal type

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

D: GCS 9 (E1M5V3), pupil unequal Ø 2,5 mm/4 mm, Light


Reflex +/+
E: T (ax): 36,5 oC
Secondary Survey
Left temporal region :
I : Hematomea (+), Edema (+)
P : Tenderness (+), Crepitation (-)
Laboratory Result
WBC : 12,9 x 103 / μL

RBC : 4,35 x 106 / μL

HGB : 12,5 g/dL

HCT : 38,3 %

PLT : 176x 103/ μL

CT / BT : 8‘00” /2’00”

Blood Sugar : 115 mg/dl

Ureum : 25 mg/dl

Creatinin : 0,7 mg/dl

GOT / GPT : 59/29 μ/L


Thorax X-ray
Head CT scan
WORKING DIAGNOSIS : - Mild head injury GCS 9 (E2M5V2)
- EDH at Left Temporal Region

MANAGEMENT : • O2
• Apply IVFD
• Medicaments
• Consult to senior Neurosurgeon
Advice: Proceed Craniectomy
No.
Name : Mr. I Sex : Female
Age : 40 years No. Reg : 653029

Main complaint : Abdominal distention

History taking : The complaint had been apparent for 1 week. Her
abdomen is distended gradually. There were no events of
vomiting and fever before.

Defecation : Normally
Micturation : Normally
Physical Examination

General Conditions:
Moderate illness/well nourished/composmentis

Vital sign:
BP : 110/80 mmHg
PR : 84x/mnt, regular, adequate.
RR : 20x/mnt.
T(Ax) : 36,9 °C
PHYSICAL EXAMINATION
Abdomen
I : Abdominal distended

A : Bowel sound normally

P : Tenderness (+), solid, warm

P : Tympani
Abdominal X-Ray
Abdominal USG
Abdominal
CT Scan
Chest X-Ray
Laboratory Result
WBC : 12,4x 103 /μL

RBC : 4.13x 106/μL

HGB : 11.1g/dL

HCT : 34%

PLT : 488x 103/μL

CT / BT : 8’30”/3’30”

Blood Sugar : 120 mg/dl

Ureum : 27 mg/dl

Creatinin : 0,50 mg/dl

SGOT/SGPT : 42/78 u/l


WORKING DIAGNOSIS : Pancreatic Cyst

MANAGEMENT :  Apply IVFD


 Medicaments
 Consult to Senior Digestive Surgeon
advice : Conservative
No.
Name : Mrs. BI Sex : Female
Age : 60 years No. Reg : 653013

Main complaint : Wound on parietal region


Case : The condition had been apparent for 4 hours before the
patient admitted to the hospital, there were pain, and no
active bleeding
Mechanism of : She was working on her house when suddenly she
injury slipped and fell and hit her head on the edge of the table
Sustained injury : Head
Symptom & sign : Wound
Examination : Physical examination, CT
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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


abdominal type

C: BP : 130/70 mmHg, PR : 80x/minute, regular, adequate

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


+/+, all motoric muscle function are normal
E: T (ax) : 37,1 oC
Secondary Survey
Parietal region :
I : Seen lacerated wound size 5x1 cm. Edema
(-) active bleeding (+)
P : Tenderness (-), Crepitation (-)
Head CT Scan
WORKING DIAGNOSIS : - Mild head injury GCS 15
- Vulnus laceratum at parietal region

MANAGEMENT : • Medicament
• Proceed Wound Care
No.
Name : Mr. HT Sex : Female
Age : 15 years No. Reg : 653025

Chief complaint : Decrease of consciousness

History taking : This condition has been apparent for 1 day before
admitted to the hospital due to head injury. History loss
of consciousness (+) nausea (+) vomiting (-).
Mechanism of : He was riding motorcycle in high speed, then he loose
injury his balance and fall down with his head and face facing
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 :20 x/minutes, spontaneous, symmetric, thoraco


abdominal type

C: BP :120/ 70 mmHg, HR :88 x/minute, regular, adequate

D: GCS 14 (E4 M6 V4), pupil equal Ø 2,5 /2,5 mm , LR +/+

E: T (ax) : 36,7 oC
Secondary Survey
Right zygoma region :
I : Seen excoriated wound size 2x1 cm, edema(+),
hematoma(+), active bleeding(-), deformity (-)
P : Tenderness (+), Crepitation (-)
Laboratory Result
WBC : 12,6 x 103 / μL

RBC : 4,18 x 106 / μL

HGB : 12,6 g/dL

HCT : 37 %

PLT : 344 x103/ μL

CT / BT : 7 ‘00” / 3 ’ 00”

Blood Sugar : 84 mg/dl

Ureum : 21 mg/dl

Creatinin : 0,5 mg/dl

GOT / GPT : 19/ 19 μ/L


Thorax X-ray
Head CT Scan
WORKING DIAGNOSIS : Mild head injury GCS 14 (E3M6V5)

MANAGEMENT : • O2
• Medicaments
• Report to senior neurosurgeon
advice : Conservative

PROGNOSIS : Good
FOLLOW UP : Vital sign
No.
Name : Mr. H Sex : Male
Age : 19 years No. Reg : 653012

Chief complaint : Decrease of consciousness

History taking : This condition has been apparent for 8 days before
admitted to the hospital due to head injury, he’s been
awake in the last 4 days, History loss of consciousness
(+) nausea (+) vomiting (-).
Mechanism of : He was riding motorcycle in high speed, then he loose
injury his balance and fall down with his head and face facing
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 :18 x/minutes, spontaneous, symmetric, thoraco


abdominal type

C: BP :110/ 70 mmHg, HR :68 x/minute, regular, adequate

D: GCS 14 (E4 M6 V4), pupil equal Ø 2,5 /2,5 mm , LR +/+

E: T (ax) : 37,1 oC
Secondary Survey
Right zygoma region :
I : Seen excoriated wound size 4x3 cm, edema(+), hematoma(+),
active bleeding(-), deformity (-)
P : Tenderness (+), Crepitation (-)
Laboratory Result
WBC : 15,5 x 103 / μL

RBC : 4,18 x 106 / μL

HGB : 12,6 g/dL

HCT : 37 %

PLT : 191 x103/ μL

CT / BT : 78‘00” / 2 ’ 00”

Blood Sugar : 71 mg/dl

Ureum : 28 mg/dl

Creatinin : 0,4 mg/dl

GOT / GPT : 29/ 26 μ/L


Thorax X-ray
Head CT Scan
WORKING DIAGNOSIS : Mild head injury GCS 14 (E4M6V4)

MANAGEMENT : • O2
• Medicaments
• Report to senior neurosurgeon
advice : conservative

PROGNOSIS : Good

FOLLOW UP : Vital sign


No. 3
Name : Ms. MA Sex : Female
Age : 18 years No. Reg : 653026

Chief complaint : Decreased of consciousness


History taking : Suffered since 5 hours before admitted to the hospital
due to traffic accident. There was history of vomiting .
Prior medical care at Gowa hospital
Mechanism of : She was riding motorcycle as a passanger, and
injury suddenly the motorcycle stopped and she fell down, with
her head face the ground
Injury sustain : Head
Symptom & sign : Decreased of consciousness
Examination : Physical examination, laboratory examination, cervical x-
ray, chest x-ray, head CT scan
PHYSICAL EXAMINATION
Primary Survey
A: Partial obstruction → oropharyngeal tube and apply ETT

B: RR : 12 x/minutes, spontaneous, symmetric, thoraco


abdominal type

C: BP : 110/70 mmHg, HR : 80 x/minute, regular, adequate

D: GCS 3X ( E1M2VX ), pupil unequal Ø 3/4,mm , LR +/+

E: T (ax) : 37,5oC
Secondary Survey

Left frontal region :


I : Seen excoriated wound size 4 x 2
cm, edema (+), hematoma(-)
P : Tenderness difficult to evaluated
Laboratory Result
WBC : 29,7 x 103 / μL

RBC : 4,11 x 106 / μL

HGB : 12,3 g/dL

HCT : 37 %

PLT : 272 x 103/ μL

CT / BT : 8‘00” / 3’ 00”

Blood Sugar : 128mg/dl

Ureum : 17 mg/dl

Creatinin : 0,5 mg/dl

GOT / GPT : 36 / 20 μ/L


Head CT
Scan
WORKING DIAGNOSIS :  Severe Head injury GCS 3X ( E1M2VX )

MANAGEMENT :
 O2
 IVFD
 Medicaments
 Report to senior neurosurgeon
advice : immediately trepanation
No.
Name : Mr. I Sex : Male
Age : 45 years No. Reg : 651445

Chief complaint : Headache

History taking : This condition has been apparent for 2 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 hit a tree, and fall down with his head and face, 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 :24 x/minutes, spontaneous, symmetric, thoraco


abdominal type

C: BP :110/ 70 mmHg, HR :88 x/minute, regular, adequate

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

E: T (ax) : 36,8 oC
Secondary Survey
Frontal region :
I : Seen lacerated wound size 4x2 cm (+),
hematoma(+), excoriation (-), active bleeding(-),
deformity (-)
P : Tenderness (+), Crepitation (-)

Zygoma and nasal region:


I : Seen deformity (+) edema (+) and hematome (+)
on both zygoma region, wound (-), excoriation (-),
active bleeding (-)
P: Tenderness (+), Crepitation (+)
Laboratory Result
WBC : 6, 8 x 103 / μL

RBC : 1, 80 x 106 / μL

HGB : 15, 0 g/dL

HCT : 16, 8 %

PLT : 167 x103/ μL

CT / BT : 7 ‘00” / 3 ’ 00”

Blood Sugar : 137 mg/dl

Ureum : 46 mg/dl

Creatinin : 1, 1 mg/dl

GOT / GPT : 52 / 29 μ/L


Skull X-
Ray
Thorax X-ray
Head CT
Scan
WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
Maxillofacial Injury
MANAGEMENT : • O2
• Medicaments
• Report to senior neurosurgeon
advice : conservative
• Report to senior plastic surgeon
Advice : elective operation

: Good
FOLLOW UP : Vital sign
THANK YOU