EMERGENCY CASE

REPORTS
th

Tuesday, March 06 , 2013

SURGERY DEPARTMENT
RS. Wahidin Sudirohusodo

EMERGENCY ROOM
WAHIDIN
SUDIROHUSODO
GENERAL HOSPITAL

EMERGENCY CASE REPORT

Thursday, March 06th
2013
Ambulation
: 1 Patient
Hospitalized

patients

Observation

patient

Operated

patient

Death

patient

Total

patients

WAHIDIN SUDIROHUSODO
HOSPITAL

Name : Mr. S

Sex Male

Age

MR 597756

: 41 years old

Chief
complain
History
taking

: Pain at the whole abdominal wall

Defecation

: Defecation (-) 1 day

Micturation

: Catheterized

: Suffered since 2 days before admitted to hospital. There

was nausea (+), vomiting (+) > 5x / day, febris (+). There
was history abdominal pain at the right upper region since 1
month ago. Diarrhea (-)
Prior medical care at maros hospital

General Status
Severe illness / well nourish / conscious

Vital Sign
BP : 110/70 mmHg
PR : 104x/mnt, strong, reguler,
RR : 32x/mnt, symmetric L=R, thoracal type.
T(Ax) : 38,4C

Local status
Abdomen :
I: Seen convex, not followed
breath motion, color same with
vicinity, tumor mass (-), darm
contour (-), darm steifung (-)
A: bowel sound (+), decreased
P: Tenderness (+) whole
abdominal abdomen, defans
muscular (+), tumor mass (-)
P: Tapping pain (+), dullness
Rectal examination :
Sphincter was loose
Mucosa was smooth
Ampulla was collapse
Tumor mass (-)
Gloves : stool (-), slime (-), blood (-)

Laboratory Result
WBC

12,52 x 103 /
:
L

Natrium : 136 mmol/l

RBC

: 4,15 x 106 / L

Kalium

HGB

: 11,7 g/dL

Chloride : 95 mmol/l

HCT

: 35,7 %

HBsAg

: positive

PLT

: 697 x 103

Albumin

: 2,3

CT / BT

: 800 / 230

Blood
Sugar

: 113 mg/dl

Ureum

: 76 mg/dl

Creatinin

: 0,8 mg/dl

SGOT/SGP
: 37/36 u/l
T

/ L

: 4,2 mmol/l

Bilirubin
: 2,2
total
Bilirubin
: 1,5
direk

Chest X-Ray

USG

WORKING
DIAGNOSIS
MANAGEMENT

PROGNOSIS

Fair

FOLLOW UP

Vital Sign and acute abdominal sign

Generalize Peritonitis e.c susp rupture of

liver abces
IVFD
NGT
Medicaments
Report to senior Digestive Surgeon :
Advice : Laparatomy exploration

Operation Procedure

Patient laid supine position under GA

Desinfection prosedure and drapping
Midline incision 20 cm, deepend to peritoneum
Open peritoneum, seen redish liquid 500 cc, fibrin at the all
cavum abdominal
Perform exploration, seen rupture liver abcess at segmen 5,
aspiration with dispo 10 cc, seen pus.
Drainage abcess liver, wash cavum abdominal
Apply 2 drainage
Stitched wound layer by layer
Operation finished

POST OP
DIAGNOSIS

: Generalize Peritonitis e.c rupture of

liver abces

PROGNOSIS

Fair

FOLLOW UP

Vital Sign
Abdominal sign
Drain production

Nam
: Mr. I
Sex
: Male
e
14 years No.
56 51
Age :
:
old
Reg
60
Chief complaint : Wound at the face
History taking

: Suffered since 1 hour before admitted to the hospital

due to self accident. There was no history loss of
consciousness , vomiting (-), convulsion (-).

Mechanism of
injury

: He was running in his home, suddenly he felt down and

his head bumped to the door.

Injury sustain
: face
Symptom & sign : Pain and wound
Examination
: Physical examination

PHYSICAL EXAMINATION
Primary Survey
A: Clear
B: RR :20 x/minutes, spontaneous, symmetric,
thoraco abdominal type
C: BP :110/70 mmHg, HR :84 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 Zygomatic region :

I : Seen lacerated wound size
3 x 1 cm, edema(-),
hematoma(-), active
bleeding(-)
P : Tenderness (+)

WORKING
DIAGNOSIS

: Lacerated Wound at the Face

MANAGEMENT

: Wound toilet stitched wound

Medicaments
Patient discharge

PROGNOSIS

: Good

Name : Mrs. H

Sex

: Female

No.
: 59 77 81
Reg
Chief complaint : Decreased of consciousness
Age

: 32 years old

History taking

Mechanism of
injury
Injury sustain

: Suffered since 6 hours before admitted to the hospital.

There was history loss of consciousnes, no vomiting.
History with cronic headache and hypertention (+),
syncope (+). Prior medical care at Gowa Hospital
: He walking in the house, suddenly she fall down and
head bump to the floor.
: Head

Symptom & sign : Decreased of consciousness

Examination

: Physical examination, laboratory examination, Head CT

Scan

PHYSICAL EXAMINATION
Primary Survey
A: Clear
B: RR : 24x/minutes, spontaneous, symmetric,
thoraco abdominal type ,
C: BP : 150/70 mmHg, HR :86 x/minute, regular,
adequate
D: GCS 10 (E2M5V3), pupil equal 2,5 mm /
2,5 mm , LR +/+
E: T (ax) : 37,2 C

Secondary Survey

WNL

Laboratory Result
WBC

13,98

RBC

3,91

x 106 / L

HGB

10,6

g/dL

HCT

32,6

PLT

241 x 103/ L

CT / BT

700 / 2 30

x 103 / L

Blood Sugar :

111 mg/dl

Ureum

23 mg/dl

Creatinin

0,7 mg/dl

GOT / GPT

17 / 9 /L

Head CT-Scan

WORKING
DIAGNOSIS

: ICH at right Frontoparietal

MANAGEMENT

: O2

Region
IVH
IVFD
Medicaments
Report to senior neurosurgeon
advice : Imediately
Craniectomy

Operating Procedure
Patient laid supine under GA
Disinfection and draping procedure
Perform horseshoe incision deepen until
pericranium make flap
Perform EVD at left ventrikel and
continue with 1 burrhole and craniotomy
with craniotom seen bulging of
duramater
Open dura seen udem of cerebri evacuate
ICH about 40 cc, control bledding
Make durafacial flap
Closed the wound with 1 vacum drain
Operation finish

POST OP
DIAGNOSIS

: ICH at right Frontoparietal

PROGNOSIS

: Fair

FOLLOW UP

: Vital sign and GCS

Region
IVH

THANK YOU