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    Kasus Toraks

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    Aldhi Tri Budhi
    The document summarizes 3 emergency cases seen at the hospital's surgery department on January 9th, 2016. Case 1 involved a 61-year-old male who fell from a ladder and sustained a pneumothorax, rib fractures, and clavicle fracture. Case 2 was a 17-year-old male who suffered a stab wound to the right neck from an arrow. Case 3 involved a 33-year-old male who crashed his motorcycle and sustained blunt chest trauma and left rib fractures. All 3 patients were treated, monitored, and had good prognoses.

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    © All Rights Reserved
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    Kasus Toraks

    Uploaded by

    Aldhi Tri Budhi
    37 views31 pages
    The document summarizes 3 emergency cases seen at the hospital's surgery department on January 9th, 2016. Case 1 involved a 61-year-old male who fell from a ladder and sustained a pneumothorax, rib fractures, and clavicle fracture. Case 2 was a 17-year-old male who suffered a stab wound to the right neck from an arrow. Case 3 involved a 33-year-old male who crashed his motorcycle and sustained blunt chest trauma and left rib fractures. All 3 patients were treated, monitored, and had good prognoses.

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    kasus toraks

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    kasus toraks

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    The document summarizes 3 emergency cases seen at the hospital's surgery department on January 9th, 2016. Case 1 involved a 61-year-old male who fell from a ladder and sustained a pneumothorax, rib fractures, and clavicle fracture. Case 2 was a 17-year-old male who suffered a stab wound to the right neck from an arrow. Case 3 involved a 33-year-old male who crashed his motorcycle and sustained blunt chest trauma and left rib fractures. All 3 patients were treated, monitored, and had good prognoses.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    37 views31 pages

    Kasus Toraks

    Uploaded by

    Aldhi Tri Budhi
    The document summarizes 3 emergency cases seen at the hospital's surgery department on January 9th, 2016. Case 1 involved a 61-year-old male who fell from a ladder and sustained a pneumothorax, rib fractures, and clavicle fracture. Case 2 was a 17-year-old male who suffered a stab wound to the right neck from an arrow. Case 3 involved a 33-year-old male who crashed his motorcycle and sustained blunt chest trauma and left rib fractures. All 3 patients were treated, monitored, and had good prognoses.

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    EMERGENCY CASE

    REPORTSth

    Saturday, January 9 , 2016

    SURGERY DEPARTMENT

    EMERGENCY ROOM
    WAHIDIN
    SUDIROHUSODO
    GENERAL HOSPITAL

    Saturday, January 9th, 2015

    Ambulation

    Patient

    Hospitalized

    Observation

    Operated

    Death

    Patient

    Total

    3 Patients

    3 Patients
    Patient
    1 Patients

    No. 1
    Nam
    : Mr. y
    Sex
    : male
    e
    61 years
    No.
    Age :
    : 740500
    old
    Reg
    Main complaint : Pain at the right chest
    History taking

    : Suffered since 4 hours before admitted to the hospital.


    There was no history of loss of conciousness, no history
    of projectile vomiting. No history of seizure.

    Mechanism of
    injury

    : He was climbing a ladder 2 metres high to fixed speaker


    at mosque, then He tripped and fell with his upper back
    bumped to the ground

    Injury sustain
    : back
    Symptom & sign : Decreased of consciouss
    Examination
    : Physical examination, Laboratory examination, thorax
    -ray

    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear
    B: RR 22 x/minutes, spontaneous,asymmetric,
    thoraco abdominal type
    C: BP :130/ 80 mmHg, HR : 88 x/minute, regular,
    adequate
    D: GCS 15 (E4M6V5), pupil equal 2.5/2.5 mm ,
    Light Reflex +/+
    E: T (ax) : 36,3 oC

    Secondary Survey
    Thorax Region :
    I : Seen no symmetric right and
    left, movement of right
    hemithorax less than lef
    hemithorax, skin color same
    with its vicinity.
    P :Tenderness (+), vocal
    fremitus decreased at right
    hemithorax
    P: hiper sonor at right apex,
    sonor at left hemithorax thorax,
    tapping pain (+) at right
    posterior hemithorax
    A: Decreased breathing sound

    Laboratory Result
    WBC

    : 10,02 x 103 / l

    RBC

    : 4,77 x 106 / L

    HGB

    : 14,02 g/dL

    HCT

    : 37,5 %

    PLT

    : 310 x 103/ L

    PT / APTT

    : 18,0 / 25,5

    Blood Sugar : 119mg/dl


    Ureum

    : 18 mg/dl

    Creatinin

    : 0,60 mg/dl

    GOT / GPT

    : 47/ 23 /L

    Thorax X-ray

    WORKING
    DIAGNOSIS

    : Right Pneumothorax due to

    MANAGEMENT

    : Oxygenation

    Blunt chest trauma


    Multiple facture of right posterior
    ribs II, III, IV, V and VI
    Close fracture of right clavicle
    bone 1/3 lateral

    IVFD
    Medicaments
    Report to senior Thorax and
    Vascuar Surgeon
    advice : Immediate Chest Tube
    Insertion
    Konsult to orthopedic
    department advice : Apply mitella

    Post OP
    diagnosis

    Right Pneumothorax due to


    blunt chest trauma
    Multiple facture of right
    posterior ribs II, III, IV, V and
    VI
    Close fracture of right
    clavicle bone 1/3 lateral

    PROGNOSIS

    : good

    FOLLOW UP

    : Vital sign and chest tube +

    WSD

    No. 3
    Nam : Mr. I
    Sex
    : Male
    e
    No.
    Age
    : 17 years
    : 739195
    old
    Reg
    Main complaint : Stab wound at right neck
    History taking

    : The condition had been apparent since 2 hours ago


    before admitted to the hospital. There was no history of
    nausea and vomitting. Prior medical care at Pelamonia
    Hospital.
    Mechanism of
    : The patient was ride a motorcycle, there was another
    injury
    motorcycle get closer to him and suddenly he was get
    punctured by an arrow from right direction.
    Sustained Injury : Right neck
    Symptom & sign : Wound and pain
    Examination
    : Physical examination, Thorax X-Ray, Cervical X-Ray
    done

    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear
    B: RR :22 x/minute, spontaneous, symmetric,
    thoraco abdominal type
    C: BP : 130/80 mmHg, HR : 88 x/minute, regular,
    adequate
    D: GCS 15 (E4M6V5), pupil equal 2,5 /2,5
    mm, Light Reflex +/+
    E: T (ax) : 36,7 oC

    Secondary Survey
    Right Neck Region :
    I : Seen punctured wound size 0,5 x
    0,5 cm
    with arrow remains, edema (+),
    there was
    hematoma (but not found
    expanding
    hematoma from observation), no
    active
    bleeding, not found buble which
    came out
    from the wound, deformity (-)
    P: Tenderness (+), palpable carotic
    artery
    pulsation at right and left neck,

    Laboratory Result
    WBC

    14,8 x 103 / L

    RBC

    4,49 x 106 / L

    HGB

    HCT

    PLT

    PT / APTT

    11,4 / 24,1 detik

    Blood Sugar

    128 mg/dl

    Ureum

    16 mg/dl

    Creatinin

    0,75 mg/dl

    GOT / GPT

    17 / 10 /L

    Urine

    0,4 cc/kgBW/24 hours

    13,1 g/dL
    Na
    : 137 mmol/ L
    38 %
    K
    : 3,1 mmol/ L
    224 x103/ L
    Cl
    119 mmol/ L

    Cervical X-Ray

    Thorax X-Ray

    WORKING
    DIAGNOSE

    MANAGEMENT
    :

    Vulnus Ictum at Anterior Neck


    Zone II Region + Corpus
    Alineum

    O2
    IVFD
    Medicaments
    Report to Senior Thorax
    Surgeon
    advice : Arrow Extraction
    Exploration

    OPERATION PROCEDURE
    Patient laid supine under GA
    Disinfection and draping procedure
    Perform incision following line of the wound,
    deepen until reach the tip of corpus
    alineum (arrow)
    Seen tip between musculus
    sternocleidomastoideus
    Extraction the corpus alineum, bleeding
    control
    Close wound layer by layer
    Operation done

    POST OP
    DIAGNOSE

    : Vulnus Ictum at Anterior Neck

    PROGNOSA

    : Good

    FOLLOW UP

    : Vital sign

    Zone II Region + Corpus


    Alineum

    Wound care

    Neck Zone

    Penetrating Neck Trauma


    Algoritm

    No.5
    Nam : Mr. M
    Sex
    e
    Age : 33 years No.
    old
    Reg
    Chief complaint : Chest Pain

    : Male
    : 739697

    History taking

    : Suffered since 4 hours before admitted to the hospital .


    No history loss of consciousness , no vomiting. Prior
    medical care at Pangkep Hospital.

    Mechanism of
    injury

    : He was riding a motorcycle with helmet and high speed then,

    Injury sustain

    suddenly he trying avoid a car then he crashed to another


    stopping car with his chest bumped first

    Chest

    :
    Symptom & sign : Physical examination, laboratory examination, thorax X
    Examination
    : ray

    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear
    B: RR :24 x/minute, spontaneous, symmetric,
    thoraco abdominal type
    C: BP :120/ 80 mmHg, HR : 90 x/minute, regular,
    adequate
    D: GCS 15 (E4 M6 V5), pupil equal 2,5 /2,5
    mm , LR +/+
    E: T (ax) : 36,7 oC

    Secondary Survey
    Thorax region :
    I : Compliance of chest wall was limitted
    because pain. Movement of the left
    hemithorax is same with right hemithorax,
    no edema, no haematoma, no wound
    P : Vocal fremitus of the left hemithorax
    same with right, tenderness
    P : sonor, left = right side
    A : Breath sound left = right hemithorax

    Laboratory Result
    RBC

    3
    : 16,14 x 10 /
    L
    : 4,79 x 106 / L

    HGB

    : 14,4 g/dL

    HCT

    : 41 %

    PLT

    : 191 x 103

    WBC

    / L

    PT / APTT : 10,1/ 20,4


    Blood
    Sugar

    : 146 mg/dl

    Ureum

    : 33 mg/dl

    Creatinin

    : 1, 34 mg/dl

    SGOT/SGP
    : 60/ 75 u/l
    T

    Thorax AP X-Ray

    WORKING
    DIAGNOSE

    PROGNOSIS
    MANAGEMENT

    : Trauma Tumpul Thorax


    Fracture of Left Posterior Ribs
    VI,VII,VIII

    : Good
    : O2

    IVFD
    Medicaments
    Report to Senior Thorax and
    cardiovascular
    surgeon,
    Advice : Concervative

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