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EMERGENCY SURGICAL SERVICES

Thursday, December 21st 2017

Consultant On Site :
dr. Ismail Bastomi, SpOT

The Attending Doctor :


Chief : dr. Faisal Armi Lubis
Chief OK : dr. Anizhom Tito Sampurno
OK : dr. Embong Wicaksono
dr. Aulia Muhardi
P1 : dr. Febian Aji Wicaksono
dr. Tinton Ardiyan
P2/P3 : dr. Hendry Dimas PF
dr. Chandra Bobby
HCU : dr. Nurindah D. Utami
Ward : dr. Rangga KM
dr. Sylvia N. Saing
Traumatic patient : 2 patient
Non traumatic patient : 4 patient
Total : 6 patient
TRAUMA CASES (2)

1. Nurlela / ♀ / 68 Years Old


Closed moderate head injury of GCS 10 + SDH on right temporal lobe
+ ICH on right temporoparietal lobe + Cerebral edema

2. Kiki Amilia / ♀ / 10 Years Old


Closed mild head injury GCS 15 + EDH of left frontotemporal lobe +
Cerebral edema
NON TRAUMA CASES(4)

1. Salsabila Nadifa / ♀ / 2 Years Old


Exposed VP Shunt

2. Nurul bin Bujang / ♀ / 75 Years Old


Perforation of duodenum part 1 post exploratory laparotomy billroth II

3. Sahrul bin Kruyek/ ♂ / 47 Years Old


Liver abscess + anemia

4. Meidewi Letisha/ ♀ / 4 Years Old


Pneumothorax spontan dextra ec lung TB on therapy +
hypoalbuminemia
TRAUMA CASES
1. Nurlela / ♀ / 68 Years Old
Admitted on Thursday, December 21st 2017 at 00.55 PM

ANAMNESIS
Decreasing of conciousness after having a traffic accident.
She was hit by a motorcycle from side direction, while she was walking.
Patient fell with her head hit a hard thing.
(± 24 hours before admission)
(Reffered from BARI Hospital)

PRIMARY SURVEY
A. Clear
B. RR : 22 x/mnt
C. BP : 140/90 mmHg
PR : 88 x/mnt
T : 36,7 ° C
D. GCS : E2M5V3 =10, Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY

On right frontal region


I : hematom (+), lacerated wound about
1 cm in size, irregular edge, subcutis base

On right orbital region


I : Hematom at palpebra superior (+)
RADIOLOGY FINDING
Head CT-Scan
SDH on right temporal lobe + ICH on right temporoparietal lobe +
cerebral edema.
LABORATORY FINDING
Hb : 10,1 gr/dl (12-16 gr/dl)
Ht : 30 vol % ( 40-48vol%)

DIAGNOSIS
Closed moderate head injury of GCS 10 + SDH on right temporal lobe +
ICH on right temporoparietal lobe + Cerebral edema

MANAGEMENT
 Head up 30º
 ATS 1500 IU IM
 IVFD NaCl gtt xxv/m (Fluid demand 1800cc/24 hours)
 Ceftriaxone 1 gram / 12 hours IV
 Tramadol 100 mg/12 hours IV
 Manitol 250cc/6 hours IV
 NGT
 Urethral catheter
 Craniotomy Decompresion

Patient was treated in the ICU


INTRA OPERATIF
We performed 4 burrholes.
We found SDH ± 20 cc and ICH ± 30 cc.
Subdura hematome and intracranial hematome were evacuated.
We performed duroplasty using temporal fascia.

POST OPERATIF DIAGNOSIS


SDH on right temporal lobe + ICH on right temporoparietal lobe
Patient was treated in the ICU
2. Kiki Amilia / ♀ / 10 Years Old
Admitted on friday, December 22nd 2017 00.17 at AM

ANAMNESIS
Headache
Her head was hit by a car while she crossed the road. Patient fell and
her head hit a hard thing.
(± 2 days before admission)
(Reffered from Fadhilah Prabumulih Hospital)

PRIMARY SURVEY
A. Clear
B. RR : 18 x/mnt
C. BP : 90/60 mmHg
PR : 96 x/mnt
T : 36,6 ° C
D. GCS : E4M6V5 : 15 Pupil Isochor, Light Reflex +/+
SECONDARY SURVEY

On right palpebra region


I : Edema (+)
RADIOLOGY FINDING
Head CT Scan
Soft tissue swelling, Cerebral edema (+), EDH of left
frontotemporal lobe
LABORATORY FINDING
Hb : 11,1gr/dl (12-16 gr/dl)
Ht : 34 vol % ( 40-48vol%)

DIAGNOSIS
Closed mild head injury GCS 15 + EDH of left frontotemporal lobe +
Cerebral edema

MANAGEMENT
 NRM 10L / minute
 Head up 30º
 IVFD NaCl 0,9% gtt xx/ minute
 Pro Craniotomy emergency

Patient was treated in the ward


NON TRAUMA CASES
1. Salsabila Nadifa / ♀ / 2 Years Old
Admitted on Thursday, December 21st 2017 at 00.40 PM

ALLOANAMNESIS
Exposed VP Shunt .
± 1 week before admission her parent complained her vp shunt was
exposed, fever (-).
History of VP shunt on April 2017.
History of Laparotomy due to adhesive on May 2017.

VITAL SIGN
Sens : Compos mentis
HR : 98 x/mnt
RR : 24 x/mnt
T : 36,9 °C
PHYSICAL EXAMINATION

On Right Parietal Region


I: Exposed VP shunt (+)
LABORATORY FINDING
Hb : 14,1 gr/dl (12-16 gr/dl)
Ht : 42 vol % ( 40-48vol%)
Leukosit : 11.400 /mm3 (5000-10000/mm3)
Trombosit : 411.000/mm3 (150.000-450.000/mm3)
DIAGNOSIS
Exposed VP Shunt

THERAPY:
 IVFD RL gtt x/minute
 Ceftriaxone 200 mg / 12 hours IV
 Paracetamol 100 mg/ 8 hours IV
 Remove VP Shunt

Patient was treated in the ward


INTRA OPERATIF
 We identified through the vp shunt tube, pus (-).
 We did debridement and the vp shunt tube is removed.
 We performed open wound management.

POST OPERATIF DIAGNOSIS


Exposed vp shunt

Patient was treated in the ward


2. Nurul bin Bujang / ♀ / 75 Years Old
Admitted on Thursday, December 21st 2017 at 01.45 PM

ANAMNESIS
Vomit
± 6 days before admission patient complained vomit.
History of laparotomy due to perforation of duodenum part I, defecate
(+), flatus (+).
(Reffered from Hermina Hospital, Palembang)

VITAL SIGN
Sens : CM
BP : 150/90 mmHg
HR : 90 x/mnt
RR : 20x/mnt
T : 37,0 °C
PHYSICAL EXAMINATION

Abdominal region
I: flat, scar operation(+)
P: soft
P: tympani
A: bowel sound (+)

NGT :
Brownish

RT : TSA was good, Ampulla was not collapse, Mass (-)


HS : feces (+), blood (-)
RADIOLOGY FINDING
Hermina hospital
USG Abdomen (19/12/2017)
Obstruction on distal of gaster
LABORATORY FINDING
Hb : 10,0 gr/dl (12-16 gr/dl)
Ht : 31,3vol % ( 40-48vol%)
Leukosit : 11.230 /mm3 (5000-10000/mm3)
Trombosit : 280.000/mm3 (150.000-450.000/mm3)
Albumin : 3,4 mg/dL (3,5-5,5 mg/dL)
Protein total : 6,3 mg/dL (6,0-8,0 mg/dL)
DIAGNOSIS
Perforation of duodenum part 1 post exploratory laparotomy billroth II

THERAPY:
 IVFD RL: D5 gtt xxx/minute
 Ceftriaxone 1 gr / 12 hours IV
 Ranitidine 50 mg / 12 hours IV
 Fasting
 NGT
 Urethral Catheter
 Sugesstion endoscopy

Patient was treated in the ward


3. Sahrul bin Kruyek/ ♂ / 47 Years Old
Admitted on Thursday, December 21st 2017 at 11.20 PM

ANAMNESIS
Pain of the right upper abdomen
± 5 days before admission, patient complained pain of the right upper
abdomen. Fever (+), nausea (+), vomit (-), appetite decreased.
(Consulted from Interna Departement)

VITAL SIGN
Sens : Compos mentis
BP : 110/70 mmHg
HR : 90 x/mnt
RR : 22 x/mnt
T : 37,2 °C
PHYSICAL EXAMINATION

Region
I : flat
P : mass was palpable on right upper abdomen
P : dullness
A: bowel sound (+)

DE :
TSA was good, ampulla was
not collaps, mass (-)
HS : Feses (+), Blood (+)
RADIOLOGY FINDING
USG FAST
Fluid (-)
RADIOLOGY FINDING
USG Abdomen (Muhammadiyah Hospital)
Susp multiple liver abscess multiple
RADIOLOGY FINDING
Rontgen thorax AP (Muhammadiyah Hospital)
Right pleura effusion
LABORATORY FINDING
Hb : 8,1 gr/dl (12-16 gr/dl)
Ht : 23 vol % ( 40-48vol%)
Leukosit : 19,0/mm3 (5000-10000/mm3)
Trombosit : 442.000/mm3 (150.000-450.000/mm3)
DIAGNOSIS
Liver abscess + anemia

THERAPY:
IVFD RL gtt XX/minute
Ceftriaxone 1 gram / 12 hours IV
Metronidazole 500 mg / 8 hours IV
CT Scan Abdomen

patient was treated in the ward


4. Meidewi Letisha/ ♀ / 4 Years Old
Admitted on Thursday, December 21st 2017 at 06.00 PM

ANAMNESIS
Shortness of breath
± 1 weeks ago before admission, patient complained shortness of
breath.
History of bleeding cough (+)
History of fever (+)
History of trauma (-)
History of medication antituberculotic drugs ± 1 weeks
(Consulted from pediatric departement)

VITAL SIGN
HR : 74 x/mnt
RR : 60 x/mnt
T : 36,6 °C
PHYSICAL EXAMINATION

Thorax region
I : Asymetric, Right < Left
P : Hypersonor on right hemithorax
A: Vesicular decrease on the right hemithorax
RADIOLOGY FINDING
Thorax X-ray
Pneumothorax dextra
LABORATORY FINDING
Hb : 10,2 gr/dl (12-16 gr/dl)
Ht : 30 vol % ( 40-48vol%)
Leukosit : 13.500 /mm3 (5000-10000/mm3)
Trombosit : 585.000/mm3 (150.000-450.000/mm3)
Albumin : 2,9 mg/dL (3,5-5,5 mg/dL)
Natrium : 135 mEq/L (135-155 mEq/L)
Kalium : 4,5mEq/L (3.5-5.5 mEq/L)
DIAGNOSIS
Pneumothorax spontan dextra ec lung TB on therapy +
hypoalbuminemia

THERAPY:
 Pro chest tube dextra

patient was treated in the ward


POST CHEST TUBE
Production : (-)
Undulation : (+)
Air bubble : (+)
Expiratory bubble : (+)

VITAL SIGN POST CHEST TUBE


SpO2: 99 %
RR : 52x/m
PR : 120x/m

POST OPERATIF DIAGNOSIS


Pneumothorax spontan dextra ec lung TB

Patient was treated in the ward


EMERGENCY REPORT
1. Prayuto bin Sumpeno / ♂ / 70 Years Old
Admitted on Wednesday, December 20th 2017 at 02.17 PM

PREOPERATIF DIAGNOSIS
ICH on left parietal lobe + IVH + Cerebral edema

INTRA OPERATIF
We performed 5 burrholes.
We found blood clot ± 40 cc and lysis ± 20 cc.
Blood clot and lysis were evacuated.
We performed duroplasty using temporal fascia.

POST OPERATIF DIAGNOSIS


ICH on left parietal lobe + IVH + Cerebral edema
Patient was treated in the P1
RADIOLOGY FINDING
Head CT-Scan
ICH on left temporoparietal lobe + IVH + cerebral edema.
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