Soleman Yunus.pptx

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