EMERGENCY CASE REPORTS

Wednesday, March 5th, 2014

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Wednesday, March 5th 2014

Ambulation : 2 Patients

Hospitalized : 3 patients

Observation : Patients
Operated : 2 Patients
Death : Patient

Total : 5 patients
No. 1
Name : Mr.N Sex : Male
Age : 26 year old No. Reg : 653704

Chief complaint : Burn injury

History taking : The condition had been apparent since 30 minutes
before admitted to the hospital. There were no history
loss of consciousness, vomiting and breathless.
Mechanism of : He was selling meatball and suddenly appeared fire
injury from the stove and strike his face and right arm
Injury sustain : Face, right arm,
Ssymptom & sign : Pain, wound
Examination : Physical examination.
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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

abdominal type

C: HR : 80 x/minute, regular, adequate

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

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

Face Region :
I : Seen burn wound gr I-IIa 4%
P : Tenderness (+)

Right Arm Region :

I : Seen burn wound gr I-IIa 3%
P : Tenderness (+)
 Laboratory Result
WBC : 15,7 x 103 / L Na : 136

RBC : 4,52 x 106 / L Kalium : 3,4

HGB : 14,7 g/dL n Klorida : 102

HCT : 42,7 % Albumin: 3,9

PLT : 218 x103/ Lm

CT / BT : 800 / 300

Blood Sugar : 170 mg/dl

Ureum : 19 mg/dl

Creatinin : 0,5 mg/dl

GOT / GPT : 25/ 17 /L

WORKING DIAGNOSIS : - Burn injury grade I-II a 7%

MANAGEMENT : IVFD
Medicaments
Report to senior plastic surgeon
advice : Resuscitation and wound care

PROGNOSIS : GOOD

FOLLOW UP : Vital Sign

Wound care
No. 2
Name : Mrs. R Sex : Female
Age : 34 years old No. Reg : 65 36 47

Chief complaint : Decreased of consciousness

History taking : This condition had been apparent since 3 hours before
admitted to the hospital due to traffic accident. There
were history of vomiting, and no seizure.

Mechanism of : She was riding motorcycle with high velocity then

injury suddenly she struck the stone in the street then she lost
her balance. She fell down to the ground and her head
bumped to the asphalt. Next mechanism unclear.
Injury sustain : Head
Symptom & sign : Decreased of consciousness
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 : 110/70 mmHg, HR : 82 x/minute, regular, adequate

D: GCS 10 ( E3M5V2 ), pupil anequal 3mm/2,5mm , LR +/+

E: T (ax) : 36,8 oC
Secondary Survey

Left frontal region :

I : seen excoriated wound size 3x2
cm edema (+), hematoma (-),
deformity (-)
P:Tenderness difficult to evaluated,
crepitating (-)
Right parietal region :
I : seen lacerated wound size 3 cm,
edema (+), hematoma (-), deformity (-)
P : Tenderness difficult to evaluated,
crepitating (-)
Laboratory Result
WBC : 27,9 x 103 / L

RBC : 3,99 x 106 / L

HGB : 11,6 g/dL

HCT : 34,9 %

PLT : 221 x 103/ L

CT / BT : 800 / 300

Blood Sugar : 153 mg/dl

Ureum : 20 mg/dl

Creatinin : 0,5 mg/dl

GOT / GPT : 40 / 23 /L
Head CT Scan
WORKING DIAGNOSIS : Moderate Head injury GCS 10 ( E2M5V3 )
EDH at Right Parietoocipital region
ICH at Left Parietal region

MANAGEMENT : O2
IVFD
Medicaments
Report to senior neurosurgeon
advice : immediate craniectomy
 Operating Procedure
Patient laid supine under GA
Disinfection and draping procedure
Perform horse shoe incision , deepen until
pericranium, released fascia
Perform 4 burr holes, continue craniectomy with
craniotom
Perform hanging dura, seen EDH 40 cc, evacuated
hematome
Control bleeding, pair inmplant fibrin glue
Hanging duramater
Close the wound layer by layer and apply 1 vacuum
drain
Operation finished
WORKING POST : Moderate Head injury GCS 10 (E2M5V3)
DIAGNOSIS EDH at Right Parietooccipital region
ICH at Left Parietal region

PROGNOSIS : Fair

FOLLOW UP Vital Sign, GCS

No. 3
Name : Mr. M Sex : Male
Age : 23 years old No. Reg : 653743

Chief complaint : Headache

History taking : This condition had been apparent since 6 hours before
admitted to the hospital due to traffic accident. History
loss of consciousness (-) vomiting (-), convulsion (-).

Mechanism of : He was riding a motorcycle then suddenly another

injury motorcycle struck from his left. He fell down to ground
with his head bumped to the asphalt.

Injury sustain : Head, face,

Symptom & sign : Headache
Examination : Physical examination
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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

abdominal type

C: BP :120/ 70 mmHg, HR :80 x/minute, regular, adequate

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

E: T (ax) : 36,7 oC
Secondary Survey
Left frontal region :
I : Seen stitched wound size 4 cm, edema(-), hematoma(-),
active bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)

Left zygoma region :

I : Seen stitched wound size 3 cm, edema(-), hematoma(-),
active bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)

Left orbital region :

I : seen edema (+), hematom (-)
P : Tenderness (-), crepitating (-)
Laboratory Result
WBC : 12,6 x 103 / L

RBC : 5,19 x 106 / L

HGB : 15,1 g/dL

HCT : 44,5 %

PLT : 254 x 103/ L

CT / BT : 600 / 200

Blood Sugar : 130 mg/dl

Ureum : 32mg/dl

Creatinin : 0,8 mg/dl

GOT / GPT : 53 / 123 /L

WORKING DIAGNOSIS : Lacerated wound at left frontal and
zygoma

MANAGEMENT : O2
IVFD
Medicaments
Wound toiletstitched wound
Patient discharge

PROGNOSIS : Good

FOLLOW UP : Vital sign

 No. 4
Name : Ms. P Sex : Female
Age : 17 years old No. Reg : 653607

Chief complaint : Pain at the Right lower abdominal

History taking : The pain had been apparent for 4 days. The pain started in
the central abdomen and one day before has shifted and
settle in the right lower abdomen . Followed by nausea and
vomitting. She feel pain at right lower abdomen when
coughing. There was history of fever before. There was no
history of delayed Menstrual cycle, and her menstrual
cycle just cleared about one week ago. Prior medical care
at Manokwari Hospital than refer to wahidin sudirohusodo
hospital.
Defecation : Normally
Micturation : Normally
 Physical Examination

General Conditions:
Moderate illness/well nourish/composmentis

Vital sign:
BP : 120/80 mmHg
PR : 96x/mnt, regular, adequate.
RR : 18x/mnt.
T(Ax) : 36,5C
PHYSICAL EXAMINATION
Abdomen
I : Flat. Skin color same with vicinity, Follow breath motion, no bowel
contour, no bowel motion. No tumor mass

A : Bowel sound normally

P : Localized tenderness (+). Defans muscular (-). Mc Burney pain (+).

Rovsing sign (+), Blumberg sign (+)
P : Tympani, tapping pain (+)
 Digital Rectal Examination

Sphincter ani was tight,

Mucous was smooth,
Ampula was empty

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

Laboratory Result
WBC : 8,8 x 103 /L

RBC : 4,58 x 106/L

HGB : 13,7 g/dL

HCT : 39,5 %

PLT : 437 x 103/L

CT / BT : 800/300

Blood Sugar : 73 mg/dl

Ureum : 21 mg/dl

Creatinin : 0,4 mg/dl

SGOT/SGPT : 15/10 u/l

 Kalesaran Score Labeda Score
Mual +7 +4
Muntah +11 +2
Demam +7 +7
Nyeri Batuk +15 +4
Nyeri Ketok +5 +10
Defans lokal -13 -11
Leukositosis -11 -7
Gender -6
TOTAL +21 3
Interpretasi Kalesaran score Labeda Score
Operated > 19 > - 11
Observation - 15 s.d 19 -57 s.d -11
Not Appendicitis < -15 < -57
USG
WORKING DIAGNOSIS : Acute appendicitis

MANAGEMENT : IVFD
Medicaments
Consult to Senior Digestive Surgeon
advice : immediate appendectomy
 OPERATION PROCEDURE
Patient lied in supine position with GA
Disinfection and draping procedure
Performed grid iron incision, deepen until peritoneum
Performed exploration, seen appendix cataralis
at retro ceacal
Performed antegrade appendectomy continue with
purse string
Bleeding control
Close the wound layer by layer
Done
POST OP DIAGNOSIS : Appendicitis Chataralis

PROGNOSIS : Good

FOLLOW UP Vital Sign

Acute abdomen
No. 5
Name : Mrs. G Sex : Female
Age : 57 years old No. Reg : 303630

Main complaint : Pain at left knee

Condition : The condition had suffered for 30 minutes before the
patient was taken to the hospital. There were no events
of vomiting, nausea and unconsciousness.
Mechanism of : The patient was walking inside her house,then suddenly
injury she slipped and fell with her left knee bump at the
ground.

Sustained Injury : Left knee

Symptom & sign : pain
Examination : Physical examination, genu X-Ray
Done
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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

abdominal type

C: BP: 110/70 mmHg, PR: 90 x/minute, regular, adequate

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

Reflex +/+
E: T (ax): 36,7 oC
Secondary Survey
Left knee region :
I : Seen Deformity (+), swelling (+),
hematoma (+), wound (-)
P: Tenderness (+), crepitation (+)

ROM :Active and passive movement of

the knee joint can not be
evaluated due to pain
NVD :Sensibility is good, pulsation of
the dorsalis pedis artery is
palpable.
Capillary refill time <2
 Laboratory Result
WBC : 9,6 x 103 / L

RBC : 3,77 x 106 / L

HGB : 11,4 g/dL

HCT : 34,4 %

PLT : 228 x 103/ L

CT / BT : 800/300

Blood Sugar : 91 mg/dl

Ureum : 13 mg/dl

Creatinin : 0,8 mg/dl

GOT / GPT : 32/31 /L

Knee X-Ray
WORKING DIAGNOSIS : Close fracture of the Left patella

MANAGEMENT : Apply IVFD

Report to Orthopaedic , advice :
Apply Kocher slab

Plan for ORIF

 Semester I
Makalah I
Makalah II Semester IV
Stase 8 Sub Bagian
Makalah III
(Nasional)

Makalah Akhir

DSTC Semester IX
Perioperatif

Semester X
Panutan
Santun
Jujur
Empati