EMERGENCY CASE REPORTS

Monday, December 4 2017

SURGERY DEPARTMENT

EMERGENCY ROOM
Wahidin Sudirohusodo General Hospital
Makassar
EMERGENCY CASE REPORT
Monday, December 4 2017
Ambulation : 1 Patient
Hospitalized : 12 Patients
Observation : - Patient
Operated : 2 Patient
Death : - Patient
Total : 13 Patients
Wahidin Sudirohusodo General Hospital
Makassar
 Name : Mr. I A Age : 57 yo
e RM : 825427 DPJP : dr. WS

Chief complaint : Bloated abdomen

History taking : This condition had been apparent since 1 days ago with
severe abdominal pain and vomitted, there’s no fever,
no hematokezia and no change of bowel habbit, there’s
no history of difficult to defecation before,no history of
pass surgical intervention,trauma,or any comorbid
illness. Micturition was normal and last defecation is 2
days before and no more flatulence since
yesterday,The patient was early treated at Ibnusina
hospital given IVFD, insert nasogastrictube -> seen
200cc yellow to green but no feculent,
catheter,antibiotic, and analgaetic so he felt no more
pain when he arrived to our hospital.
General Status
Moderate illness / well nourish / conscious

Metabolic status
BMI : 58/1,622 = 21,3

Vital Sign
BP : 130/80 mmHg
PR : 88 x/mnt, strong, reguler,
RR : 22 x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 36,8°C
PHYSICAL EXAMINATION
Secondary Survey
Abdominal Region :

I : distended, follow breath motion, skin

color same with its vicinity,
bowel contour (-), bowel motion (-)
A : peristaltic (+) sound increased
P : tenderness (+) at whole abdominal,
defans muscular (-)
P : tapping pain (+) , tympani
DIGITAL RECTAL EXAMINATION

1. Spinchter anus was tight

2. Mucous was smooth
3. Ampulla collapse
4. Handschoen : theres no faeces, no blood, and
mucous
 Clinical Diagnostic
• Total Small Intestinal Obstruction
CT Scan Abdomen
 Laboratory Findings
• Hb : 11,7  Ur : 12
• Hct : 35  Cr : 0,96
• WBC : 24.200  GDS : 210
• PLT : 181.000  Na : 140
 INR : 1,04 K : 4,6
 PT : 11.3  Cl : 105
 APTT : 25.8  HBsAg : non reactive
 SGOT :7 Increase
 SGPT : 10 Normal
Decrease
 Working Diagnose
• Total Small Intestinal Obstruction
 Management
• IVFD, Rehidration
• Medicaments
• Consult to Digestive Surgeon
– Immediate Laparotomy Exploration
 Intraoperative Finding
• Perform midline incision  deepen until peritoneum
• Open Peritoneum  seen hematoma + stoolcell + blood about 1000cc
• Seen internal herniation of sigmoid colon to ileal vasa + volvulus
• Seen bowel segmen 200 cm from Treitz ligamen to distal ileum was
necrose, and strangulated
• Seen strangulated segmen of sigmoid colon
• Perform resection anastomose Ileo-ileal end to end 200cm from Treitz
ligamen to 10cm from ileocolica
• Perform resection sigmoid + anastomose end to end
• Rinse abdominal cavity
• Close the wound layer by layer with one drain left
Operation Picture
 Post Operative Diagnose
• Total small intestinal obstruction et causa
internal hernia + volvulus
 Prognosis and follow up
• Prognosis : Dubia
• Follow up :
– Vital Sign
– Acute abdomen
– Nutrition
– Laboratory control -> electrolit
– Wound care
 Name : Mrs. AJ Age : 24 yo
e RM : 825430 DPJP : dr. DW

Chief complain : Decrease of conciousness

History taking : The condition has been apparent 3 days ago before
admitted to the hospital due to traffic accident. There was
history of loss of consciousness and since that moment he
not regained his fully status of conscious. There was
history of vomit,no convulsion. The patient was carried out
from Sidrap general Hospital, insert ett,ivfd,catheter and
medicaments
Mechanism of : He was ride a motorcycle without helmet suddenly a high
injury speed motorcycle from the opposite direction hit him. He
was thrown away and his head landed first onto the
asphalt
 Physical Examination

Primary Survey :
A : Clear
B : RR : 22x/minute, symmetric, vesicular,
sonor, rh -/-, wh -/- on ventilator controled
 Physical examination
Circulation :
- Pulse 82x/minutes, reguler, adequate, Blood
pressure : 100/70 mmhg
-Disability : GCS 4x (E1M3Vx), ishochoric pupil 4/4
mm
Exposure : Temperature 36,5 oC
PHYSICAL EXAMINATION
Secondary Survey
Orbital region:

I : Seen hematoma at the

right orbital, no active
bleeding (-)

Right parietal region

I : seen hematoma, no active

bleeding
P : crepitation (-)
 Clinical Diagnostic
• Traumatic Brain Injury GCS 4x (E1 M3 Vx)
Head CT-Scan

EDH Volume 8 x 3,5 x 14 / 2 = 196 cc

 Laboratory Findings
• Hb : 10,7  Cr : 0,78
• Hct : 30,7  GDS : 126
• WBC : 11.000  Na : 149
• PLT : 161.000 K : 4.0
 INR : 1,09  Cl : 113
 SGOT : 35
 SGPT : 13
Increase
 Ur : 28 Normal
Decrease
 Working Diagnosis
• Traumatic Brain Injury GCS 4x (E1 M3 Vx)
• Epidural hematoma at the right temporoparietal
region
• Closed fracture at the right temporal region and
greater wings of right sphenoid
 Management
• O2 via ventilator
• head up 30o
• IVFD
•Medicaments
• Consult to Neuro Surgeon
– Immediate Craniectomy + Hematoma Evacuation
 Intra Operative Finding
• Question mark Incision
• Perform 2 burr hole  with craniotome 
craniectomy
• Obvious EDH about 65 cc  evacuation the
hematome
• Hanging duramater
• Durafacial flap
• Bleeding control
• Suture layer by layer with 1 drain left
Operation Picture
 Prognosis and follow up
• Prognosis : Dubia ad malam
• Follow up :
– Vital sign
– GCS
– Wound care