EMERGENCY CASE REPORTS

Saturday, November 19th 2016

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Saturday, November 19th 2016

Ambulation : - Patient

Hospitalized : 11 Patient

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

Total : 13 Patients
No 1
Name : Ms. NP Sex : Female
Age : 18 years old No. Reg : 779762
DPJP : WS

Chief complain : Pain at lower right abdomen

History taking : This condition has been suffered since 3 days before admitted to the
hospital. At first the patient felt pain at the epigastrium. Then the pain
refered to the lower right abdomen. There were history of nausea and
vomiting. There was fever that has been suffered since 2 days ago. There
was no history of the same complain before. Menstruation was on reguler
period every month and no complain about dysmenorrhea before
Defecation : Normally
Micturition : Normally
Examination : Phyical examination, laboratory examination, abdominal USG
 PHYSICAL EXAMINATION
GENERAL STATUS

Moderate ilness/well nourished/conscious

VITAL SIGN

BP: 110/80 mmHg

P: 92 x/I

RR: 20 x/i

T: 38,6 C
 LOCAL STATUS
Abdominal Region
I : flat, follow breath motion, skin color same with its vicinity, no
darm contour and no darm steifung
A : peristaltic (+) normal
P : supple, there was tenderness and local defense at McBurney
region, no palpable mass, Rovsing sign (+), Blumberg Sign (+)
P : tympany
 Digital Rectal Examination
Sphincter ani was tight
Rectal mucosa smooth
Ampulla recti was not collapsed
There was tenderness at 11-12 o’clock

Handschoen: blood (-), feces (+), slime (-)

 Laboratory Result
WBC : 25,8 x 103 / μL
RBC : 4,99 x 106 / μL
HGB : 14,6 g/dL
HCT : 45 %
PLT : 243 x 103/ μL
PT/APTT : 12,3/29,6
Blood Sugar : 117 mg/dl
 Urinalysis Result
Color : Yellow
pH : 6,0
Spesific Gravity : 1.010
Protein : Trace
Glucose : Negative
Bilirubin : Negative
Urobilinogen : Normal
Keton : + / 15
Nitrit : Negative
Blood : Negative
Leukocyte : Negative
Leukocyte sediment :1
Eritrocyte sediment : Negative
Crystal sediment : Negative
Epithel cell sediment : 14
Abdominal USG
Kalesaran Score Alvarado Score Labeda Score
Nausea 7 Migration pain 1 Nausea 4
Vomiting 11 Anorexia 1 Vomiting 2

Fever 7 Nausea & vomiting 1 Fever 7

RLQ Tenderness 2 Coughing Pain 4
Coughing Pain 15
Rebound pain 1 Tapping Pain 10
Tapping Pain 5
Elevated Temperature 1 Local Defense 16
Local Defense 10
Leukocytosis 2 WBC 6
WBC 15 Shift of WBC to the left 1 Gender -6
TOTAL 70 TOTAL 10 TOTAL 43

Interpretasi: Interpretasi: Interpretasi:

Skor < -49: normal Skor 1-4: observasi Skor <-57: bukan
Skor -49 -20: observasi Skor 5-6: antibiotik appendicitis
Skor >20: operasi Skor 7-10: operasi Skor -57 sampai -10:
observasi
Skor > -10: operasi
WORKING : Localized Peritonitis Due To Suspicious Perforated
DIAGNOSIS Appendicitis

MANAGEMENT : Planning
• IVFD
• Medicaments
• Laparotomy + Appendectomy
 OPERATING PROCEDURE
• Patient was laid in supine postion under general anesthesia.
• Desinfection and drapping procedure.
• Perform midline incision 1 cm below umbilicus, deepen sharply
until seen peritoneum
• Open peritoneum, identificate the junction of taenia until reached
caecum
• Identificate appendix, seen appendix at antecaecal and perforation
at one third middle of appendix
• Decided to perform appendectomy procedure with double ligation
suture
• Wash peritoneal cavity until seen clean
• Bleeding control
• Sutured operating wound layer by layer
• Operation finished.
DIAGNOSIS : Perforated Appendicitis

FOLLOW UP : • Vital sign

• Acute Abdominal Sign

PROGNOSIS : Good
No.
Name : Mr HM Sex : Male
Age : 39 years old No. Reg : 779804
DPJP : WA

Chief complain : Headache

History taking : Suffered since 9 hours before admitted to the hospital due to
accident. There was history of vomiting. There were no history of
loss consiousness and seizure. Prior medical care at Jeneponto
General Hospital (was given oxygenation, IVFD and medicaments)
Mechanism of : He was riding the motorcycle then hit by another car. He fell with
injury his head bumped to the asphalt.

Injury sustain : Head

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

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

Bronchovesicular type

C: BP : 110/70 mmHg, HR : 82x/minute, regular, adequate

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

+/+
E: T (ax) : 36,7°C
Secondary Survey

Frontal Region
I : Seen excoriated wound, no active bleeding, seen edem and hematom at
left orbital region and right zygomaticum region
P: There was tenderness, no crepitation
Secondary Survey

Parietal Region
I : Seen stitched wound size 5 cm, no active bleeding, seen edem, no
hematom
P: There was tenderness, no crepitation
 Laboratory Result
WBC : 16,1 x 103 / μL
RBC : 4,2 x 106 / μL
HGB : 12 g/dL
HCT : 38 %
PLT : 245 x 103/ μL
PT/APTT : 10,4/26,7
Blood Sugar : 143 mg/dl
Natrium : 144 mg/dl
Kalium : 4,2 mg/dl
Chloride : 103 mg/dl
 Head CT Scan

ICH= 4 x 2.5 x (1.842-1.032) = 4.02 cc

2

EDH= 8 x 2 x (5.435-1.124) = 34.48 cc

2
DIAGNOSE :  Traumatic Brain Injury GCS 15
 Epidural Hematom at Left Temporoparietal Region
 Intracerebral Hematom at Right Temporal Region

MANAGEMENT : • O2
• IVFD
• Medicaments
• Planning: immediate craniectomy evacuation
 OPERATION PROCEDURE
• Patient was laid in supine position under general anesthesia
• Desinfection and drapping procedure
• Perform Horse shoe inscision at right temporal, deepen until
pericranium, make fascia flap, seen linear fracture
• Perform 1 burrhole and craniotomy with craniotom
• Open pericranium, seen epidural hematome about 30 cc,
evacuate hematome
• Perform dura fascia flap
• Bleeding control, washing with Nacl 0.9 %
• Sutured operation layer by layer with one vaccum drain
• Operation finished
Operation Photos
POST OP DIAGNOSE :  Traumatic Brain Injury GCS 15
 Epidural Hematom at Left Temporoparietal Region
Intracerebral Hematom at Right Temporal Region

PROGNOSIS : GOOD

FOLLOW UP : GCS
Vital Sign
Drain Production
Wound Care
THANK YOU