EMERGENCY CASE REPORTS

Wednesday , February 12th, 2014

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Wednesday, February 12th 2014

Ambulation : - Patients

Hospitalized : 4 Patients

Observation : Patients
Operated : 4 Patients
Death : Patients

Total : 4 Patients
Name : Ch. A Sex :Male
Age : 1 years old MR :650850
Chief complaint : Burn wound

History taking : The condition had ben apparent since 1 hours before admitted to the
hospital due to accident.

Mechanism of injury : He was playing in the kitchen when suddenly he get sprinkled by a boiled
water.

Injury sustain : Body, Bottom, Leg

Symptom & sign : Pain, burn wound
Examination : Physical examination. Laboratory
 Primary Survey
A: Clear, patent
B: RR : 28 x/mnt, spontaneous, symmetric, and thoracoabdominal type.

C: BP : 100/60 mmHg, Pulse : 100 x/mnt, adequate, regular.

D: GCS 15 (E4M6V5), pupil equal 2.5 mm/2.5 mm, LR +/+

E: T: 36,7C
Secondary Survey
Right hemithorax + abdomen

I: Seen burn wound grade II A 7%, Hiperemis (+)

P: Tenderness (+)

Back Region
I: Seen burn wound grade I-II A 18%, Hiperemis (+)
P: Tenderness (+)
Secondary Survey
Right tight Region

I: Seen burn wound grade I-II A 14%, Hiperemis (+)

P: Tenderness (+)

Left tight Region

I: Seen burn wound grade II A 4%, Hiperemis (+)
P: Tenderness (+)
Laboratory Result
WBC : 20,9 x 103 / L PT : 13.6

RBC : 5,07 x 106 / L APTT : 32.2

HGB : 12.5 g/dL Natrium : 134mmol/l

HCT : 37,6 % Kalium : 3.8 mmol/l

PLT : 409 x 103 / L Cloride : 113 mmol/l

CT / BT : 800 / 300 HbsAg : Nonreactive

Blood Sugar : 151 mg/dl

Ureum : 16 mg/dl

Creatinin : 0.4 mg/dl

SGOT/SGPT : 49/21 u/l

WORKING DIAGNOSIS : Combutio grade I-II A 43 %

MANAGEMENT : fluid resusitasion with modification

baxter formula
Apply Foley Catheter
Medicament
Consul plastic surgery
Advice : debridement

PROGNOSIS : good

FOLLOW UP : Vital sign and wound healing

POST OP DIAGNOSIS : Combutio grade I - II A 43 %

PROGNOSIS : Good

FOLLOW UP : Vital sign and wound healing

Name : Mrs. E Sex : Female
Age : 14 years old No. Reg : 650845

Chief complaint : Pain at the whole abdomen

History taking : Suffered since 20 days before admitted to ER. The first 15
days patient just stay at home and consume herbal
drug, the next 5 day patient was taken to Sinjai
hospital. This simptom followed by nausea, vomiting
and fever.
Micturation : Normally

Defecation : Diarrhea
General Status
Severe illness / well nourish / delirium

Vital Sign
BP : 90/60 mmHg
PR : 120x/mnt, weak, reguler,
RR : 36x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 39,5C
 Local Status
Abdominal
I : Convex, follow breath motion, skin color same with its vicinity,
bowel contour (-), bowel motion (-)
A : Peristaltic (+) decreased
P : Tumor mass (-) Tenderness (+) Defans muscular (+)
P : Tapping pain (+), hyper timpani
 Digital Rectal Examination

Sphincter tone was loose

Mucous was smooth
Ampulla fill with feces
Handscoen : blood (-), feces (+), slime (+)
 Laboratory Result
WBC : 19,3 x 103 / L Natrium : 124 mmol/l

RBC : 2,58 x 106 / L Kalium : 3,4 mmol/l

HGB : 7,4 g/dL Clorida : 92 mmol/l

HCT : 22,9 % Albumin : 2,3 g/dl

PLT : 523 x103/ L PT : 17 detik

CT / BT : 700 / 2 00 APTT : 26,0 detik

Blood Sugar : 135 mg/dl Hbs Ag : Negatif

Ig M
Ureum : 42 mg/dl : Positif / 6
Salmonella
Creatinin : 0,4 mg/dl

GOT / GPT : 20/9 /L

BNO
WORKING DIAGNOSIS : - Generelized peritonitis ec Hollow viscus
perforation ec Salmonella Typhoid
- SIRS

MANAGEMENT : Oxigenation
IVFD
NGT
Urine Catheter
Medicaments
Report to senior pediatric surgeon
advice : laparotomy exploration
 Operating Procedure
Patient laid in supine position under GA.
Sterilization and draping procedure
Midline incision 5 finger under procesus xyphoideus until 4
finger above suprapubik, deepen until peritoneum
Open peritoneum seen feses, with adhesion between
peritoneum and omentum
Released adhesion, identification hollow viscus, seen perforation
on sekum with diameter about 4x3cm, and perforation ascenden
colon on fleksura hepatika about 4x3 cm
Perform sekostomi and eksteriorisasi on asenden colon with
catheter fr-22 then fiksated
Control bleeding
Clean with NACL 0,9%
Close operating wound layer by layer with 1 drain
Operation finished
POST OP DIAGNOSIS : - Generalized peritonitis due to perforation
of sekum and flexura hepatica
- SIRS

PROGNOSIS : fair
FOLLOW UP : Vital sign, acute abdomen, and wound
healing
Name : Mr. F Sex : Male
Age : 56 years old No. Reg : 650837

Chief complaint : Stab wound at right chest

History taking : Suffered since 3 days before admitted to the hospital
due to fighting. History loss of consciousness (-)
vomiting (-). Prior medical care at Ambon Hospital with
: chest tube applied.
Mechanism of He was about to enter a backdoor of his house when
injury suddenly someone hide there stab him with a spear from
upside directions.
Injury sustain : Chest
Symptom & sign : Pain, Stab wound
Examination : Physical examination, laboratory examination, thorax X
ray
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR :28 x/minute, spontaneous, asymmetric, thoraco

abdominal type with chest tube applied

C: BP :130/ 80 mmHg, HR :112 x/minute, regular, adequate

D: GCS 15 (E4 M6 V5), pupil equal 2,5 /2,5 mm , LR +/+

E: T (ax) : 38,3 oC
Secondary Survey

Right thorax region :

I : Seen spear wound at upper right hemithorax below clavicle Chest
movement asimetric, right behind left edema(+), hematoma(-),
active bleeding(+), chest tube (+)
P: Hipersonor at right hemithorax, left sonor VF right < left
P : Tenderness (+), Crepitating (-)
A: Breath sound decreased at right thorax
Secondary Survey

Abdomen
I : Seen flat follow breath motion
A: Breath sound Normal
P: tenderness (-) TM (-)
P: Tapping pain (-) tympani

DRE: - spinter tone was tight

- mucous was smooth
- ampulla filled with the feses
Hanscoen : feses (+), Blood (-), Slime (-)
Laboratory Result
WBC : 16,2 x 103 / L

RBC : 3,92 x 106 / L

HGB : 12,7 g/dL

HCT : 39,2 %

PLT : 287 x 103 / L

CT / BT : 730 / 300

Blood Sugar : 115 mg/dl

Ureum : 57 mg/dl

Creatinin : 0,9 mg/dl

SGOT/SGPT : 129 /72 u/l

Thorax AP X-Ray
WORKING DIAGNOSE : - Vulnus ictum penetran at right hemithorax
- Right Pneumothorax
- Right Hematothrax

MANAGEMENT : O2
IVFD
Medicaments
Report to Senior thorax surgeon,
advice : thoracotomy
 Operation Procedure
Patient lied left latera decubitus GA
Desinfection & drapping Procedure
Make anterolateral incision at ICS 5 deepend until pleura
parietalis open the pleura parietalis seen blood at right
cavus thorax
Explore seem the spear cut through the superior lobe to
inferior lobe until posterior wall right thorax thoracal 8
Cut the tip of the spear, and pull the rest out of cavum
thorax.
Stitch the superior, medial and inferior lobe with continous
suture using nylon 5.0
Decorticated all the surface of the pleura viceralis
Rince with Nacl + Betadine
Close the wound layer by layer, with 1 chest tube applied
POST : - Vulnus ictum penetran at right hemithorax
OPERATIVE - Right Pneumothorax
DIAGNOSIS - Right Hematothrax
Laceration of superior lobe
Laceration of medial lobe
Laceration of inferior lobe

PROGNOSIS : Good

FOLLOW UP : Vital Sign, chest tube production

Name : Mr. I Sex : Male
Age : 29 years old No. Reg : 650817

Chief complaint : Abdominal pain

History taking : Suffered since 3 days before admitted to the
hospital. Initially he felt pain at the central abdomen.
Then spread on the right lower abdomen, and one
day ago spread to the whole abdomen. Followed by
nausea, vomiting and fever. Prior medical care at
takalar hospital.

Defecation : Normal
Micturated : Normal
 Physical Examination

General Conditions:
Moderate illness / well nourish / conscious

Vital sign:
BP : 120/70 mmHg
PR : 96 x/mnt, regular, adequate.
RR : 24 x/mnt.
T(Ax) : 37,9 C
PHYSICAL EXAMINATION
Abdomen
I : Seen flat, follow breath motion, no bowel contour, no bowel motion

A : Decreased of Bowel sound

P : Tenderness at whole abdomen ,Muscular defans (+)

P : Tympani , tapping pain (+) whole abdomen

Rectal Toucher

Sphincter ani was loose

Mucous was smooth,
Ampula filled with the feses,
No palpable mass,

Gloves : Faeces (+), blood (-), slime (-)

 Laboratory Result
WBC : 9,9 x 103 / L Na : 139

RBC : 4,82 x 106 / L K : 4.3

HGB : 13,9 g/dL Cl : 107

HCT : 42 % HbSAg : (-) negatif

PLT : 218 x 103 / L

CT / BT : 800 / 300

Blood Sugar : 97 mg/dl

Ureum : 27 mg/dl

Creatinin : 0,8 mg/dl

SGOT/SGPT : 19/14 u/l

WORKING DIAGNOSIS : Generalized peritonitis due to suspect appendix
perforation

MANAGEMENT : IVFD
Apply NGT
Apply Foley Catheter urine
Medicaments
Report to Senior Digestive Surgeon
advice : Immediate Laparotomy
 OPERATION PROCEDURE
Patient laid supine under GA
Disinfection and drapping procedure
Performed midline incision 2 fingers above umbilicus
until suprapubic
Deepen until peritoneum, open peritoneum seen pus
Identification hollow fiscus, seen perforation of
appendix, perform appendektomi, continue with
tabacsac
Wash cavum abdomen with Nacl until clean
Close wound layer by layer with 1 drain
Operation done
POST OP DIAGNOSIS : Generalized peritonitis due to perforation of appendix

PROGNOSIS : Good

FOLLOW UP : Vital Sign

Abdominal Pain