EMERGENCY CASE REPORTS

Thursday, July 9th, 2015

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
 Thursday, July 9th 2015

Ambulation : - Patients

Hospitalized : - patients

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

Total : 2 patients
No. 1
Name : Ch. I Sex : Male
Age : 16 years old No. Reg : 718543

Chief complaint : Headache

History taking : The condition had been apparent since 5 hours before
admitted to the hospital. There were history of loss of
consciousness, no vomiting. The prior medical care at
Pangkep Hospital.
Mechanism of : He was driving a motorcycle when suddenly got hit by a
injury car from side direction. Next mechanism was unknown
Injury sustain : Head
Symptom & sign : Pain

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 : 100/70 mmHg, HR :90 x/minute, regular, adequate

D: GCS 14 (E3 M6 V5), pupil equal Ø 2/2 mm , LR +/↓

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

Left orbital region :

I : Seen palpebral hematom (+), excoriated (+) 1 x 0,5 cm, No
wound
P : Crepitation (-)
 Laboratory Result
WBC : 11,6 x 103 / Μl

RBC : 5,09 x 106 / μL

HGB : 13,7 g/dL

HCT : 48 %

PLT : 171 x 103/ μL

CT / BT : 8‘00” / 3’00”

Blood Sugar : 110 mg/dl

Ureum : 57 mg/dl

Creatinin : 0,9 mg/dl

GOT / GPT : 31/14 μ/L

Head CT Scan
WORKING DIAGNOSIS :- Mild Head Injury GCS 14 (E3M6V5)
- EDH at Frontoteporal basal Sinistra

MANAGEMENT :• O2
• IVFD
• Medicaments
• Report to Senior Neuro surgeon :
Advise : Immediate Craniectomy
 Operation Procedure
• Patient laid supine under GA
• Disinfection and draping procedure
• Perform bicoronal incision, deepen until periosteum, seen
linear fracture
• Perform 3 burr holes, craniotomy used gigly saw, evacuated
30 cc
• Performed decorticated of frontal sinus, then muscle patched
• Perform hanging dura
• Close the wound layer by layer and apply 1 vacuum drain
• Operation finished
POST OP DIAGNOSIS : - Mild Head Injury GCS 14 (E3M6V5)
- EDH at Frontal Sinistra Region
- Linier fracture at left frontal bone

FOLLOW UP : • Vital sign

• GCS

PROGNOSIS : Good
No. 2
Name : Ms. W Sex : Female
Age : 29 years old No. Reg : 712246

Chief complaint : Right iliac fossa pain

History taking : The condition had been apparent since 2 days before
addmited to the hospital. There were history of nausea,
vomiting, loss of appetite, slight fever. She went to general
practinioner and had medication for it. But it was not
releaved her pain. Initial pain was in umbilical area.
Micturation : normally
General Status
Moderate illness / undernourished / conscious

Vital Sign
BP : 100/70 mmHg
PR : 88x/mnt, strong, reguler,
RR : 20x/mnt, symmetric L=R, thoracoabdominal type.
T(Ax) : 37,4 °C
T (Rctl) : 38,2 °C
 Local Status
Abdominal
I : Flat, follow breath motion, skin color same with its vicinity,
bowel contour (-), bowel motion (-)
A : Peristaltic (+)
P : Tenderness (+), muscular defans (-), Liver and spleen was
not palpable
P : Tympani, Tapping pain (+)
 Digital Rectal Examination

Sphincter tone was tight

Mucous was irregular
Ampulla filled with feces
Handscoen : blood (-), feces (+), slime (-)
 Laboratory Result
WBC : 22,2 x 103 / μL Natrium : 130 mmol/l

RBC : 4,22 x 106 / μL Kalium : 3,5 mmol/l

HGB : 12,2 g/dL Clorida : 101 mmol/l

HCT : 36% HCG test : negative

PLT : 279 x103/ μL Urine : 0,7 cc/kg BB/jam

CT / BT : 7‘00” / 3’ 00”

Blood Sugar : 118 mg/dl

Ureum : 39 mg/dl

Creatinin : 0,8 mg/dl

GOT / GPT : 39/20 μ/L

 Urinalisa
• Color : yellow Blood : Negatif
• Ph : 6,5 Lekosit : + - / 15
• Bj : >=1,030 Protein : + / 10
• Sedimen Lekosit : 1
• Glucose : Negatif Sedimen Eritrosit : 2
• Bilirubin : Negatif Urobilinogen : Normal
• Keton : Negatif Nitrit : Negatif
 Abdominal USG

Labeda Score : 30
Alvarado Score : 10
WORKING DIAGNOSIS : Acute Appendicitis

MANAGEMENT : • Oxigenation
• IVFD
• Urine Catheter
• Medicaments
• Report to senior digestive surgeon
advice : Appendicectomy