EMERGENCY CASE REPORTS

wednesday, May 27th, 2015

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
EMERGENCY CASE REPORT
Wednesday, May 27th 2015

Ambulation : - Patients
Hospitalized
: 5 patients

Observation : - Patients
Operated : 2 Patients
Death : - Patient

Total : 5 patients

WAHIDIN SUDIROHUSODO HOSPITAL

MAKASSAR
No. 1
Name : Mr.U Sex : Male
Age : 48 years old No. Reg : 713587

Chief complaint : Headache

History taking : The condition had been apparent since 2 hours before
admitted to the hospital due to falling from a height 3
meters. There were history of vomiting and decrease of
consciousness.
Mechanism of : He was on his work using a ladder, and then suddenly
injury the ladder fell, he fell down and his head bumped to the
floor.
Injury sustain : Head
Symptom & sign : Headache, Pain
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 : 80 x/minute, regular, adequate

D: GCS 15 ( E4M6V5), pupil equal 3/3 mm , LR +/+

E: T (ax) : 36,7oC
Secondary Survey

Within normal limits

 Laboratory Result
WBC : 12,0 x 103 / μL

RBC : 4,20 x 106 / μL

HGB : 11,51 g/dL

HCT : 34,4 %

PLT : 218 x 103/ μL

CT / BT : 6‘00” / 3’ 00”

Blood Sugar : 122 mg/dl

Ureum : 29 mg/dl

Creatinin : 0,60 mg/dl

GOT / GPT : 22 / 14 μ/L

Head CT Scan
WORKING DIAGNOSIS :  Traumatic Brain injury GCS 15 ( E4M6V5)
 Fracture linier at os Occipital
 Contusio cerebri regio frontalis
 Infark ganglion basalis sinistra
 Multihematosinus
MANAGEMENT :  O2
 IVFD
 Medicaments
 Report to Senior Neuro Surgeon
Advice : Conservative
No. 2
Name : Ch. L Sex : Female
Age : 4 years old No. Reg : 713643
Main complaint : Wound at face
Condition : The condition apparent for 9 hours before taken to
hospital due to traffic accident. There was no history of
vomiting and decrease consciousness. Prior medical
care at Sinjai Hospital.
Mechanism of : She was a passenger of motorcycle and when it
injury motorcycle on its way to stop, patient jumped from the
motorcycle and her head bumped to asphalt.
Sustained Injury : Head, Face
Symptom & sign : Headache,
Examination Done : Physical examination, Laboratory examination, Skull X-
Ray, water’s position X-ray, Chest X-Ray.
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR: 28x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP: 100/70 mmHg, PR: 88 x/minute, regular, adequate

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

Reflex +/+
E: T (ax): 36,8 oC
Secondary Survey
Right Supraorbita Region :
I : Seen lacerated wound size 1,5 x 1
cm, there was no active bleeding
P : Crepitation (-) tenderness (+)
Left Supraorbita Region :
I : Seen lacerated wound size 1,5 x 0.5
cm, there was no active bleeding
P : tenderness (+) crepitation (-)
Nasal Region :
I : Seen exoriated wound size 0,5 x 0,2
cm, there was no active bleeding
P : tenderness (+) crepitation (-)
 Laboratory Result
WBC : 16,5 x 103 / μL

RBC : 4,9 X 106 / μL

HGB : 13 g/dL

HCT : 38,9 %

PLT : 485 x 103/ μL

CT / BT : 8‘00”/3’00”

Blood Sugar : 90 mg/dl

Ureum : 16 mg/dl

Creatinin : 0,60 mg/dl

GOT / GPT : 33 /16 μ/L

Skull X-Ray
Water’s position X-Ray
Thorax X-Ray
WORKING DIAGNOSIS : - Traumatic Brain Injury GCS 15 (E4M6V5)
- Fracture Os Nasal

MANAGEMENT : •O2
•IVFD
• Medicaments
• Consult to senior plastic surgeon
Advice: Plan for repotition
 OPERATION PROCEDURE
• Patient laid supine under GA
• Disinfection and drapping procedure
• Nasal repotition with woldsam clem
• Put tampons in to nasal dextra
• Stitch wound at supra orbita sinistra region size 3 x 1 cm, and
supra orbita dextra region size 3 x 1 cm with nylon 5.0
• Apply butterly gips
• Operation finished
POST OP DIAGNOSIS : Farcture Os Nasal

PROGNOSIS : Good
FOLLOW UP : Vital sign
No. 3
Name : By. Ny.R Sex : Female
Age : 3 days old RM : 713627

Chief complaint : Abdominal distention

History taking : The condition had been apparent since 3 days ago before
admitted to hospital, the abdominal distention getting worst
in the last 2 days. There were history of fever, nausea and
vomitting. Prior medical care at Takalar hospital

Micturation : Normally

Defecation No defecated since born

General Status
Moderate illness /wellnourished / composmentis

Vital Sign
PR : 112x/mnt, strong, reguler,
RR : 28x/mnt, symmetric L=R, thoracoabdominal
type.
T : 36,9°C
 Local Status
Abdominal Region :
I : Distended, follow breath motion, skin color same with its vicinity, bowel
motion (-), bowel contour (+)
A : Peristaltic (+) Increase
P : Tenderness (+), muscular defans (+), Liver and spleen was not palpable
P : Hypertympani
 Laboratory Result
WBC : 5,8x 103 / μL Natrium : 141 mmol/l

RBC : 4,36 x 106 / μL Kalium : 4,6 mmol/l

HGB : 15,3 g/dL Clorida : 107 mmol/l

HCT : 44,3%

PLT : 210 x103/ μL

CT / BT : 7‘00” / 3’ 00”

Blood Sugar : 105 mg/dl

Ureum : 30 mg/dl

Creatinin : 0,30 mg/dl

GOT / GPT : 57/47 μ/L

 Digital Rectal Examination

Sphincter tone was tight

Mucous was smooth
Ampulla filled with feces
Handscoen : blood (-), feces (+), slime (-)
BNO X - ray
BNO X - ray
WORKING DIAGNOSIS : Ileus Obstruction e.c Suspec Hirsprung
disease

MANAGEMENT : . IVFD
• Urine catheter
• Orogastric Tube
• Rectal Tube
• Medicaments
• Report to senior pediatric surgeon
advice : Conservative
No. 4
Name : Ch. A Sex : Female
Age : 3 years old RM : 713627

Chief complaint : Whole Abdominal pain

History taking : The condition had been apparent since 1 week ago before
admitted to hospital, the pain getting worst in the last 2
days. There were history of fever, nausea and vomitting
(food), since then patient doesn’t eat well. Prior medical
care at Tarakan hospital
Micturation : Normally

Defecation Normally
General Status
Moderate illness /wellnourished / composmentis

Vital Sign
PR : 112x/mnt, strong, reguler,
RR : 28x/mnt, symmetric L=R, thoracoabdominal
type.
T : 36,5°C
 Local Status
Abdominal Region :
I : Distended, follow breath motion, skin color same with its vicinity, bowel
motion (-) bowel contour (-)
A : Peristaltic (+) Increase
P : Tenderness (+), muscular defans (+), Liver and spleen was not palpable
P : Hypertympani
 Laboratory Result
WBC : 15,8x 103 / μL Natrium : 141 mmol/l

RBC : 4,06 x 106 / μL Kalium : 4,6 mmol/l

HGB : 11,3 g/dL Clorida : 107 mmol/l

HCT : 33,3%

PLT : 193 x103/ μL

CT / BT : 7‘00” / 3’ 00”

Blood Sugar : 105 mg/dl

Ureum : 30 mg/dl

Creatinin : 0,30 mg/dl

GOT / GPT : 57/47 μ/L

 Digital Rectal Examination

Sphincter tone was tight

Mucous was smooth
Ampulla filled with feces
Handscoen : blood (-), feces (+), slime (-)
USG
BNO X - ray
BNO X- ray
WORKING DIAGNOSIS : Ileus obstructive partial

MANAGEMENT : • Oxigenation
• IVFD
• NGT
• Rectal Tube
• Medicaments
• Report to senior pediatric surgeon
advice : Conservative
No. 5
Name : Mrs.A Sex : Female
Age : 16 years old No. Reg : 713660
Main complaint : Pain at face
Condition : The condition apparent for 6 hours before taken to
hospital due to traffic accident. There was history of
nausea and vomiting. Prior medical care at Bantaeng
Hospital.
Mechanism of : She was riding a motorcycle and hit a traffic lamp than
injury she fell down with her head bumped to asphalt.

Sustained Injury : Head, Face

Symptom & sign : Headache,
Examination Done : Physical examination, Laboratory examination, Head
CT-Scan.
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR: 18x/minutes, spontaneous, symmetric, thoraco

abdominal type

C: BP: 110/70 mmHg, PR: 78 x/minute, regular, adequate

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

Reflex +/+
E: T (ax): 36,8 oC
Secondary Survey
Right Zygoma Region :
I : Seen exoriated wound size 5,5 x 3
cm, there was no active bleeding
P : Crepitation (-) tenderness (+)
Supra labia oris Region :
I : Seen exoriated wound size 0,6 x 0.2
cm, there was no active bleeding
P : tenderness (+) crepitation (-)
Inferior labis oris Region :
I : Seen exoriated wound size 0,6x 0,1
cm, there was no active bleeding
P : tenderness (+) crepitation (-)
 Laboratory Result
WBC : 23,2 x 103 / μL

RBC : 3,54X 106 / μL

HGB : 10 g/dL

HCT : 32 %

PLT : 263 x 103/ μL

CT / BT : 7‘00”/3’00”

Blood Sugar : 148 mg/dl

Ureum : 22 mg/dl

Creatinin : 0,50 mg/dl

GOT / GPT : 36 /28 μ/L

Head CT - Scan
Thorax X-ray
WORKING DIAGNOSIS : - Traumatic Brain Injury GCS 15 (E4M6V5)
- Maxillofacial Injury
- Fracture Dentoalveolar
- Brain Swelling

MANAGEMENT : •O2
•IVFD
• Medicaments
• Consult to senior plastic surgeon
Advice: Plan for Apply Archbarr
 OPERATION PROCEDURE
• Patient laid supine under GA
• Disinfection and drapping procedure
• Identification fracture dentoalveolar
• Apply achbarr at mandibulla and maxilla
• Stitch wound at buccal regio with vicryl 4.0
• Operation finished
POST OP DIAGNOSIS : Farcture Dentoalveolar

PROGNOSIS : Good
FOLLOW UP : Vital sign
Thank you