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EMERGENCY CASE REPORTS
Tuesday, March 06th, 2013
SURGERY DEPARTMENT
EMERGENCY ROOMWAHIDIN
SUDIROHUSODO GENERAL HOSPITAL
MAKASSAR
EMERGENCY CASE REPORT
WAHIDIN SUDIROHUSODO HOSPITALMAKASSAR
Thursday, March 06th 2013
Ambulation : 1 Patient
Hospitalized : 2 patients
Observation : - patient
Operated : 2 patient
Death : - patient
Total : 3 patients
Name : Mr. S Sex Male
Age : 41 years old MR 597756
Chief complain
: Pain at the whole abdominal wall
History taking
: 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
Defecation : Defecation (-) 1 day
Micturation : Catheterized
General StatusSevere illness / well nourish / conscious
Vital Sign BP : 110/70 mmHgPR : 104x/mnt, strong, reguler, RR : 32x/mnt, symmetric L=R, thoracal
type. T(Ax) : 38,4°C
Local statusAbdomen :I: Seen convex, not followed breath motion, color same with vicinity, tumor mass (-), darm contour (-), darm steifung (-)A: bowel sound (+), decreasedP: Tenderness (+) whole abdominal abdomen, defans muscular (+), tumor mass (-)P: Tapping pain (+), dullness
Rectal examination :Sphincter was looseMucosa was smoothAmpulla was collapseTumor mass (-)Gloves : stool (-), slime (-), blood (-)
Laboratory Result WBC : 12,52 x 103 / μL Natrium : 136 mmol/l
RBC : 4,15 x 106 / μL Kalium : 4,2 mmol/l
HGB : 11,7 g/dL Chloride : 95 mmol/l
HCT : 35,7 % HBsAg : positive
PLT : 697 x 103 / μL Albumin : 2,3
CT / BT : 8’00” / 2’30” Bilirubin total : 2,2
Blood Sugar : 113 mg/dl Bilirubin direk : 1,5
Ureum : 76 mg/dl
Creatinin : 0,8 mg/dl
SGOT/SGPT : 37/36 u/l
Chest X-Ray
USG
WORKING DIAGNOSIS : Generalize Peritonitis e.c susp rupture of liver abces
MANAGEMENT
PROGNOSIS
FOLLOW UP
:
:
:
IVFD NGT Medicaments Report to senior Digestive Surgeon : Advice : Laparatomy exploration
Fair
Vital Sign and acute abdominal sign
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
FOLLOW UP
Fair
Vital Sign Abdominal sign Drain production
Name : Mr. I Sex : Male
Age : 14 years old No. Reg : 56 51 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 woundExamination : 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 Ø 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
Age : 32 years old No. Reg : 59 77 81
Chief complaint : Decreased of consciousness
History taking : 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
Mechanism of injury
: He walking in the house, suddenly she fall down and head bump to the floor.
Injury sustain : 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 Ø 2,5 mm / Ø 2,5 mm , LR +/+
E: T (ax) : 37,2 °C
Secondary Survey
WNL
Laboratory Result
WBC : 13,98 x 103 / μL
RBC : 3,91 x 106 / μL
HGB : 10,6 g/dL
HCT : 32,6 %
PLT : 241 x 103/ μL
CT / BT : 7‘00” / 2 ’ 30”
Blood Sugar : 111 mg/dl
Ureum : 23 mg/dl
Creatinin : 0,7 mg/dl
GOT / GPT : 17 / 9 μ/L
Head CT-Scan
WORKING DIAGNOSIS : ICH at right Frontoparietal RegionIVH
MANAGEMENT : • O2• 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 RegionIVH
PROGNOSIS : Fair
FOLLOW UP : Vital sign and GCS
THANK YOU