Emergency Case Bedah UNHAS

Thursday, October 6th,2016
SURGERY DEPARTMENT
EMERGENCY ROOM
WAHIDIN SUDIROHUSODO GENERAL HOSPITAL
MAKASSAR
Thursday, October 6th

2016
Ambulation
:
1 Patient
Hospitalized
6 Patients
Observation
- Patient
Operated
- Patient
Death
- Patient
Total
7 Patients
EMERGENCY ROOM
WAHIDIN SUDIROHUSODO GENERAL HOSPITAL
MAKASSAR
No. 1
Nam
: Mr. F
Sex
e
28 Years
No.
Age
:
Chief complaint
: Headache
old
Reg
: Male
: 774570
History taking
: Suffered since 4 hours before admitted to hospital due to

fell down from the stairs. There were no history loss of
consciousness, nausea and vomiting. Prior medical care
at Pangkep Hospital
Mechanism of
injury
: He was repair the plafond suddenly he slipped and fell

down about 2 meters with head bumped to the ground
Injury sustain
: Head
Symptom & sign : headache

Examination
: Physical examination, Head CT-Scan, laboratory

examination
PHYSICAL EXAMINATION
Primary Survey
A: Clear; Cervical Spine Control
B: RR : 18 x/minutes, spontaneous, symmetric,
thoraco abdominal type
C: HR : 82 x/minute, regular, adequate
D: GCS 15 ( E4M6V5 ), pupil equal 2,5/2,5 mm ,
LR +/+
E: T (ax) : 36,6oC
Secondary Survey
Right Frontal Region :
I : Seen excoriated wound, stitched wound
size 3 cm, no hematoma, no swelling, no
active bleeding
P : Tenderness (+) Crepitation (-)
Right Temporal Region :
I : Seen excoriated wound, lacerated
wound size 6x0,2cm, no hematoma, no
swelling, no active bleeding
Right Parietal Region :
I : Seen stitched wound size 5 cm, no
hematoma, no swelling, no active bleeding
HEAD CT-SCAN
Laboratory Result
WBC
15,46 x 103 / L
RBC
3,65 x 106 / L
HGB
11,0 g/dL
HCT
33 %
PLT
300 x103/ L
Blood Sugar :
170 mg/dl
Ureum
25 mg/dl
Creatinin
0,7 mg/dl
GOT / GPT
18 / 14 /L
WORKING
DIAGNOSE
: Traumatic Brain Injury GCS 15
MANAGEMENT
: O2
( E4M6V5)
Brain swelling
IVFD
Medicaments
Report to senior neurosurgeon
advice : conservative
No. 2
Nam
: Ms. S
Sex
: Female
e
16 years No.
Age :
: 774615
old
Reg
Chief complaint : Pain at right lower abdomen
History taking
: This condition had been suffered since 4 days before

admitted to ER. At the beginning she fell pain at the
umbilical and referred to right lower abdomen. There
were fever, anorexia, nausea, vomit, pain at the right
lower abdominal when she cough. Prior medical care
at Pelamonia Hospital
Micturation
: Normally
Defecation
: Normally
General Status
Moderate illness / well nourish / conscious
Vital Sign
BP
: 110/70 mmHg
PR
: 90 x/mnt, strong, reguler,
RR
: 20 x/mnt, symmetric L=R,
thoracoabdominal
type.
T(Ax) : 37,7 C
Abdominal
Local Status
I : flat, follow breath motion, skin color same with its vicinity,
bowel contour (-), bowel motion (-)
P : tenderness (+) at Mc Burney point, Rovsing sign (+),
Blumberg sign (+), muscular defans (-)
P : tapping pain (+), tympani
A : peristaltic (+) sound normal
Digital Rectal Examination

Sphincter tone was tight
Mucous was smooth
Ampulla filled with feces
There was pain at palpation at 10-11 oclock
Handscoen blood (-), feces (+), slime (-)
Laboratory Result
WBC
: 11.2 x 103 / l
RBC
3.94 x 106 / L
HGB
12.7 g/dL
HCT
38 %
PLT
299 x 103/ L
Blood
Sugar
114 mg/dl
Ureum
32 mg/dl
Creatinine : 0.6 mg/dl

GOT/GPT
: 38/36 u/l
PT/APTT : 12.0/27.2
Plano
test
: negative
ALVARADO
SHIFTING
SCORE
PAIN
ANOREKSIA
NAUSEA &
VOMIT
1
1
PAIN AT RIGHT
FOSSA ILIAKA
TAPPING PAIN
FEVER >37,2C
LEUCOCYTOSIS
10X10/L
1
1
2
NEUTROFIL
75%
TOTAL
0
9
Alvarado
Score
M : Mual-muntah
A : Anoreksia
N : Nyeri berpindah
T : Nyeri fossa iliaca
kanan
1
1
2
R : Nyeri lepas
E : Peningkatan suhu >

37,20C
L : Leukositosis >
10.000/L
S : Jumlah neutrophil >

75%
TOTAL
Alvarado Score
5-6 :
kemungkinan
kecil
7-8 :
kemungkinan
besar
> 9 : sangat
mungkin
USG ABDOMEN
WORKING
DIAGNOSIS
: Appendicitis acute
MANAGEMENT
: IVFD
Medicaments
Report to senior digestive
surgeon
advice : immediate
appendectomy
No. 3
Nam
: Ch. I
e
Sex
: Female
No.
Age
: 5 Years: Wound
old at the head
: 774592
Chief complaint
Reg
History taking
: The condition had been apparent since 15 minute

before admitted to the hospital due to accident. There
were no history of unconsciousness, nausea, vomiting.
Mechanism of
injury
: she was playing around the hospital when suddenly she

slipped and fell down with right head bumped to the floor
Injury sustain
: Head
Symptom & sign : Pain and wound

Examination
: Physical examination
Primary Survey
A: Clear
LR +/+
E: T (ax) : 36,8oC
Secondary Survey
Right Frontal Region :
I : Seen lacerated wound size 4x2
cm, swelling, no active bleeding
WORKING
DIAGNOSE
MANAGEMENT
( E4M6V5 )
Lacerated wound at right
frontal region
: Wound care and primary suture
Medicaments
Patient discharge
No. 3
Nam
: Mr. S
Sex
e
88 Years
No.
Age
:
Chief complaint
: Headache
old
Reg
: Male
: 774594
History taking
: Suffered since 11 hours before admitted to hospital due

to fell down from the stairs. There were no history loss of
consciousness, nausea and vomiting. Prior medical care
at Syekh Yusuf, Gowa Hospital
Mechanism of
injury
: He was walking on the stairs suddenly he slipped and

fell down with head bumped to the floor
Injury sustain
: Head
Symptom & sign : Headache

Examination
: Physical examination, Head CT-Scan, Laboratory

examination
Primary Survey
C: HR : 76x/minute, regular, adequate
LR +/+
E: T (ax) : 36,9oC
Secondary Survey
Right Periorbital Region :
I : Seen hematoma, no swelling, no active
bleeding
Nose Region :
I : Seen no wound, no hematoma, no
swelling, active bleeding
P : Tenderness (-) Crepitation (-)
Right Auricular Region :
hematoma, no swelling, no active bleeding
HEAD CT-SCAN
Laboratory Result
WBC
: 24.2 x 103 / L
RBC
4.49 x 106 / L
HGB
13.8 g/dL
HCT
41 %
PLT
333 x 103/ L
Blood
Sugar
155 mg/dl
Ureum
20 mg/dl
Creatinin
0,84 mg/dl
SGOT /
SGPT
47 / 28 /L
WORKING
DIAGNOSE
MANAGEMENT
: O2
( E4M6V5)
Multiplehematosinus
IVFD
Medicaments
No. 4
Nam
: Mr. F
Sex
e
38 Years
No.
Age
:
Chief complaint
: Headache
old
Reg
: Male
: 774569
History taking
: Suffered since 10 days before admitted to hospital.

There was history loss of consciousness, no history
nausea and vomiting. Prior medical care at Bulukumba
Hospital
Mechanism of
injury
: while working in the forest, suddenly fall of the logs on

the patient's head
Injury sustain
: Head
Symptom & sign : headache

Examination
: Physical examination, Head CT-Scan, Laboratory

examination
Primary Survey
LR +/+
E: T (ax) : 36,8oC
Secondary Survey
Right Parietal Region :
hematoma, no swelling, no active
bleeding
HEAD CT-SCAN
Laboratory Result
WBC
8,55 x 103 / L
RBC
4,86 x 106 / L
HGB
14,5 g/dL
HCT
42 %
PLT
309 x 103/ L
WORKING
DIAGNOSE
MANAGEMENT
: O2
( E4M6V5)
Brain swelling
IVFD
Medicaments

Emergency Case Bedah UNHAS

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Emergency Case Bedah UNHAS

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Thursday, October 6th,2016

Thursday, October 6th

: Suffered since 4 hours before admitted to hospital due to

: He was repair the plafond suddenly he slipped and fell

Symptom & sign : headache

: Physical examination, Head CT-Scan, laboratory

: Traumatic Brain Injury GCS 15

: This condition had been suffered since 4 days before

Digital Rectal Examination

Creatinine : 0.6 mg/dl

E : Peningkatan suhu >

S : Jumlah neutrophil >

: The condition had been apparent since 15 minute

: she was playing around the hospital when suddenly she

Symptom & sign : Pain and wound

: Traumatic Brain Injury GCS 15

: Suffered since 11 hours before admitted to hospital due

: He was walking on the stairs suddenly he slipped and

Symptom & sign : Headache

: Physical examination, Head CT-Scan, Laboratory

: Traumatic Brain Injury GCS 15

: Suffered since 10 days before admitted to hospital.

: while working in the forest, suddenly fall of the logs on

Symptom & sign : headache

: Physical examination, Head CT-Scan, Laboratory

: Traumatic Brain Injury GCS 15

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