EMERGENCY CASE

REPORTS
Wednesday, July 1st 2020
SURGERY DEPARTMENT

EMERGENCY ROOM
Wahidin Sudirohusodo General Hospital
Makassar
EMERGENCY CASE REPORT
Wednesday, July 1st 2020
Ambulation : - Patient
Hospitalize
: - Patients
d
Observatio
: - Patient
n
Operated : - Patient
Death : - Patient
Wahidin Sudirohusodo General
PatientHospital
Total Makassar
: -
s
 Name : Ny. Z DPJP : SM
Age : 50 Years No. :
Reg 918727

Chief : Whole abdominal pain

complain
History : Pain experienced since 1 day ago, initially pain in
epigastric area then spread to whole abdomen. Pain
taking continues to feel like prickling pain, History Nausea, no
vomiting, a history of fever there History of the last
chapter 1 day ago, flatus (+), normal urinari, there is no
decrease in appetite.

Micturation Normal

Defecation Absent
 Physical Examination
General Status:
Active / well nourished / compos mentis
Vital Sign:
BP : 120/90 mmHg
HR: 82x/min reguler
RR: 20x/min simetric
T(Ax): 36,5°C
 Local Status
Abdominal
I : Flat, darm countur and darm steiffung (-)
A : peristaltic sound (-) metallic sound (-)
P : Supel (+), tenderness (+)Defans Difficult to evaluate
P : Tympani
Rectal
Toucher
- Sphincter ani
clamped strongly
- Smooth Mucosa
- Ampula recti
Collapse (-)
- Handscoen :
Feses(+), Blood
(-), Mucus (-)
 Clinical Diagnostic
Peritonitis Generalisata Et. Causa Susp.
Appendicitis Perforation
 Laboratory Findings

WBC : 15.000 :

HGB : 13.4 GOT/GPT : 37/49

HCT : 38 Natrium : 132

PLT : 161 Kalium : 3.8

GDS : 165 Clorida : 104

PT : 11.5 Rapid tes : IgG : NR, IgM : NR

APTT : 31.2

INR 1.12
Chest XRAY
COVID-19 SCREENING
WORKING : - Peritonitis Generalisata Et
DIAGNOSIS Causa Suspek Appendicitis
Perforation
MANAGEMENT : • IVFD
• Medicamentation
• Laparatomy Exploration
Appendictomy
 Procedure Operation
• Patien lay in supine position and under the influence of Spinal
Anaesthesia.
• Desinfection and drapping procedure.
• Midline incision from 2 cm above the umbilicus to 2 cm above the
symphisis pubis.
• Deeply sharp and blunt to the peritoneum.
• Peritoneum was opened, and pus discharged for about 100cc.
• Exploring abdominal cavity and adhesion between ileal and right iliac was
seen than adheolisis was done
• Identification of secum and appendix found that apendix was retrocaecal.
Appendix was seen reddish with 7 cm long and 2 cm in diameter. Apendiks
shaft perforation was seen 4 cm from apendix origin. Fecalith was found in
shaft apendix.
• Bleeding control and operation filled irrigation with nacl 0,9% was done
until it looks clean.
• Drain was place with 18 fr into douglas cavity
Documentation of Operation
POST OP : Peritonitis Generalisata Et Causa
DIAGNOSIS Suspek Appendicitis Perforation
PROGNOSIS : Bonam

FOLLOW UP : Vital Sign

Acute abodmen
Wound treatment
 Nam
: Tn. F Age : Age
23 yo : 25 yrs
eName : Ms. IS
RM : 860474 DPJP : AIH
DPJ
MR : 918731 : dr. FJ
P

Chief Complaint : Nasal pain

History Taking :
Nasal pain was felt since 1 hours before admitted,
after trafic accident. Neither alteration of
conciousnes, headache, nousea nor vomiting was
reported. Nouse was not bled, neither was ear.
Revere was not reported.
Trauma :
Patient post riding a bike and using helmet at the
Mecanism
time, and fell suddenly. Patient cant remember the
cause and mecanism of the accident. After the
accident, patient was able to rode his bike again and
went to hospital without any assistant
 Physical Examination
Primary Survey:
A : Clear
B : Spontan, RR: 20x/i, chest movement:
Symmetrical
C : warm exeremities, HR: 80x/i, strong and
reguler pulse,
BP : 128/87 mmHg
D : GCS : E: 4, M: 6, V: 5, pupil mm, light reflex : +/+,
not lateralitation was found.
E : T: 36,6 C
 Secondary Survey
• Nasal : I: edema (-) hematoma (-)
P: tenderness pain (-), crepitation (+)
 Clinical diagnostic
• Suspect Fracture os nasale
CT Scan 3D
 Laboratory
WBC : 9.600 Rapid Test
HGB : 17.3 IgG : NR
HCT : 49 IgM : NR
PLT : 279.000

GDS : 120

PT : 10.1
APTT : 24.9
INR : 0.97
Screening Covid -19
Work Diagnostic : Os.Nasal Fracture
Treatment : Oxygenation
IVFD
Medicamentation
Fracture Repairing : Closed Reposition
 Operational Procedure
• Patient was in supine potition an the general anastesia
• Desinfection and drapping procedure was performed on nasal area
• By identification of nasal area, deformity was seen
• Nasal repotition was decided to be perfomade, aiming to restore it into as
anatomically position as possible
• Bleeding controled
• Butterfly cast was placed in nasal area.
• One tampon was placed into nasale cavity.
• Operation was done.
Work diagnostic : • Fracture Os. Nasale

Treatment : • Oxygenation
• IVFD
• Medication
• Repaire fracture : closed repotition
Operation Documentation
DIAGNOSI POST : • Closed Fracture Os Nasal
OP

PROGNOSIS : •Bonam

EVALUASI : Vital Sign

Wound Treatment
 Name: Ms.Ny.
Name IS N AgeAge : 2565
yrsthn
RM : 860474 DPJP : AIH
RM 593019 DPJP dr. WA

Keluhan Utama : Alteration of Conciousness

Anamnesis Terpimpin :
Since 14 hours before atmitted, after fell from motorcycle. Neither
seizure, vomitting, nosebleeding nor ear bleeding was reported.

Mechanism of Trauma :
Patient was riding her motorcycle while using helmet by herself, then
suddenly another motorcycle from the opposite direction in a high
speed hit her, then patient fell and her head hit the asphalt road
causing helmet to be thrown off her head.
 Physical Examination
Primary survey
A : oropharyngeal tube attached
B : Spontaneus
RR : 20 x/m, symetrical chest movement , SpO2 98%
C : TD : 129/ 87 mmHg, N : 109 x/m, strong and regular
pulse.
D : GCS 4 (E1M1V2) , anisokor pupil 4 mm / 2,5 mm,
Light reflex + / + slow, , Lateralisation -
E : Temperature: 37,2°Celcius
Secondary survey:
Head :
I : Right periorbital hematoma, right frontal
wound had been stiched, active bleeding.
P : krepitation (-), tenderness cannot be
evaluated.
Shoulder dextra:
I: Hematom 15x9cm
P : tenderness cannot be
evaluated
 Clinical Diagnostic
• Traumatic Brain Injury GCS 4 (E1M1V2)
CT SCAN
Chest X-ray
 Laboratory
WBC : 13.100 Na : 136
HGB : 14.8 K : 3.6
HCT : 45 Cl : 101
PLT : 297.000 SGOT : 15

GDS : 99 SGPT : 23

PT : 10.6 Rapid Test :

APTT : 28.2 IgG NR

INR : 1.02 IgM NR

Ur/Cr : 14/1,32
Work Diagnostic :
• Traumatic Brain Injury GCS 4 (E1M1V2)
• ICH Frontoparietal dextra et sinistra
• EDH minimal parietal dextra
• Kontusio mesenchepalon

Treatment : Head up 30
Oksigenation 10 lpm via NRM
IVFD NaCL
Medication
Conservation
 Conservative Treatment
• Conciousness  GCS
• Respiratory Oxygenation
• Seizure  Anti convulsan (diazepam/fenitoin)
• Temperature  Temperature increasing
identification
• Sirculation  Avoid hypertension
• Urine Cateter, Fluid Balance
• Mobilisation  Avoid decubitus
• Elevation  HeadUp 30, Decrease TIK
• Electrolite Serve  Fluid Balance
• Nutrition Nutritional intake
• Bowel Care  Normal defecation
• ICP Monitoring  Sedative
Thank You