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    Surgery Department: Emergency Case Reports

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    Mohamad Zulfikar
    This document provides a summary of 5 emergency case reports from the surgery department of Wahidin Sudirohusodo General Hospital in Makassar on February 17th, 2014. It describes 5 patients who were admitted with injuries from traffic accidents, including head injuries, facial fractures, and lacerations. For each patient, it includes details of their history, examination findings, diagnostic imaging and lab results, diagnoses, and treatment plans.

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    Surgery Department: Emergency Case Reports

    Uploaded by

    Mohamad Zulfikar
    13 views34 pages
    This document provides a summary of 5 emergency case reports from the surgery department of Wahidin Sudirohusodo General Hospital in Makassar on February 17th, 2014. It describes 5 patients who were admitted with injuries from traffic accidents, including head injuries, facial fractures, and lacerations. For each patient, it includes details of their history, examination findings, diagnostic imaging and lab results, diagnoses, and treatment plans.

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    emcase

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    Dr Agus Emcase 17-2-14

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    This document provides a summary of 5 emergency case reports from the surgery department of Wahidin Sudirohusodo General Hospital in Makassar on February 17th, 2014. It describes 5 patients who were admitted with injuries from traffic accidents, including head injuries, facial fractures, and lacerations. For each patient, it includes details of their history, examination findings, diagnostic imaging and lab results, diagnoses, and treatment plans.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    13 views34 pages

    Surgery Department: Emergency Case Reports

    Uploaded by

    Mohamad Zulfikar
    This document provides a summary of 5 emergency case reports from the surgery department of Wahidin Sudirohusodo General Hospital in Makassar on February 17th, 2014. It describes 5 patients who were admitted with injuries from traffic accidents, including head injuries, facial fractures, and lacerations. For each patient, it includes details of their history, examination findings, diagnostic imaging and lab results, diagnoses, and treatment plans.

    Copyright:

    © All Rights Reserved
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    You are on page 1of 34

    EMERGENCY CASE REPORTS

    Monday , February 17th , 2014


    SURGERY DEPARTMENT

    EMERGENCY ROOM
    WAHIDIN SUDIROHUSODO
    GENERAL HOSPITAL
    MAKASSAR
    Monday, February 17th 2014

    Ambulation : 5 Patient

    Hospitalized : 4 patients

    Observation : 1 patient
    Operated : - patient
    Death : - patient

    Total : 5 patients
    No. 1
    Name : Mr. T Sex : Male
    Age : 37 years No. Reg : 651489

    Chief complaint : Decrease of consciousness

    History taking : This condition has been apparent for 8 hours before
    admitted to the hospital due to traffic accident. History
    loss of consciousness (+) nausea (-) vomiting (-).
    Mechanism of : He was riding motorcycle, suddenly he got struck by
    injury another motorcycle from his opposite direction, he
    slipped and then fell down with his head bumped to the
    ground first
    Injury sustain : Head, face
    Symptom & sign : Headache
    Examination : Physical examination, laboratory examination, head CT
    scan
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR :20 x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP :110/ 60 mmHg, HR :68 x/minute, regular, adequate

    D: GCS 12 (E3 M5 V4), pupil equal 2,5 /2,5 mm , LR +/+

    E: T (ax) : 37,0 oC
    Secondary Survey
    Left parietal region :
    I : Seen edema(+), hematoma(-), wound (-),
    deformity (-)
    P : Crepitation (-)
    Laboratory Result
    WBC : 16, 8 x 103 / L

    RBC : 4,05 x 106 / L

    HGB : 12,5 g/dL

    HCT : 37,7%

    PLT : 204 x103/ L

    CT / BT : 8 00 / 2 30

    Blood Sugar : 152 mg/dl

    Ureum : 42 mg/dl

    Creatinin : 0.8 mg/dl

    GOT / GPT : 100 / 53 /L


    Cervical X-Ray
    Head CT Scan
    WORKING DIAGNOSIS : Moderate head injury GCS 12 (E3M5V4)
    ICH at right temporal region

    MANAGEMENT : O2
    Medicaments
    Report to senior neurosurgeon
    advice : conservative

    PROGNOSIS : Good

    FOLLOW UP : Vital sign


    No. 2
    Name : Mr. L Sex : Male
    Age : 17 years No. Reg : 651445

    Chief complaint : Headache

    History taking : This condition has been apparent for 22 hours before
    admitted to the hospital due to traffic accident. History
    loss of consciousness (+) nausea (+) vomiting (-).
    Mechanism of : He was riding motorcycle in high speed, then he loose
    injury his balance and fell down with his head and face,
    bumped to the asphalt first.

    Injury sustain : Head, face


    Symptom & sign : Headache
    Examination : Physical examination, laboratory examination, head CT
    scan
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR :24 x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP :110/ 60 mmHg, HR :68 x/minute, regular, adequate

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

    E: T (ax) : 37,1 oC
    Secondary Survey
    Both orbital region :
    I : Seen edema(+), hematoma(+), in both superior
    palpebrae, wound (-), excoriation (-), active
    bleeding(-), deformity (-)
    P : Crepitation (-)

    Mandibular region :
    I : Seen deformity (+) edema (+) and hematome (+) ,
    wound (-), excoriation (-), active bleeding (-)
    P : Crepitation (+)
    Laboratory Result
    WBC : 16,3x 103 / L

    RBC : 2,88 x 106 / L

    HGB : 8,9 g/dL

    HCT : 26,8 %

    PLT : 168 x103/ L

    CT / BT : 8 00 / 2 00

    Blood Sugar : 105 mg/dl

    Ureum : 46 mg/dl

    Creatinin : 0,7 mg/dl

    GOT / GPT : 275/ 499 /L


    Head CT Scan
    WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
    Closed segmental fracture of mandibular

    MANAGEMENT : O2
    Medicaments
    Report to senior plastic surgery
    advice : elective operation

    PROGNOSIS : Good

    FOLLOW UP : Vital sign


    No. 3
    Name : Mr. K Sex : Male
    Age : 28 years No. Reg : 651494

    Chief complaint : Decrease of consciousness

    History taking : This condition has been apparent for 24 hours before
    admitted to the hospital due to traffic accident. History
    loss of consciousness (+) nausea (-) vomiting (-).
    Mechanism of : He was riding motorcycle, then he loose his balance and
    injury fall down with his head bumped to the asphalt first

    Injury sustain : Head, face


    Symptom & sign : Headache
    Examination : Physical examination, laboratory examination, head CT
    scan
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR :24 x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP :120/ 70 mmHg, HR :72 x/minute, regular, adequate

    D: GCS 12 (E3 M5 V4), pupil equal 2,5 /2,5 mm , LR +/+

    E: T (ax) : 37,0 oC
    Secondary Survey
    Right parietal region :
    I : Seen stiched wound 3x1 cm, edema(+),
    hematoma(-), wound (-), excoriation (-), active
    bleeding(-), deformity (-)
    P : Tenderness (+), Crepitating (-)
    Laboratory Result
    WBC : 16,8 x 103 / L

    RBC : 3, 80 x 106 / L

    HGB : 12,5 g/dL

    HCT : 39,7 %

    PLT : 204 x103/ L

    CT / BT : 7 00 / 3 00

    Blood Sugar : 137 mg/dl

    Ureum : 46 mg/dl

    Creatinin : 1, 1 mg/dl

    GOT / GPT : 52 / 29 /L
    Head CT Scan
    WORKING DIAGNOSIS : Moderate head injury GCS 12 (E3M5V4)
    Epidural hematoma at right temporoparietal
    region
    Subdural hematome at left parietal region
    MANAGEMENT : O2
    Medicaments
    Report to senior neurosurgeon
    advice : conservative

    PROGNOSIS : Good

    FOLLOW UP : Vital sign


    No. 4
    Name : Mr. R Sex : Male
    Age : 55 years No. Reg : 545265

    Chief complaint : Headache

    History taking : This condition has been apparent for 2 hours before
    admitted to the hospital due to accident. History loss of
    consciousness (-) nausea (-) vomiting (-).
    Mechanism of : He was sitting near the wall then he knocked the wall,
    injury and the wall fall on him and hit most of his body

    Injury sustain : Head, face


    Symptom & sign : Headache
    Examination : Physical examination, laboratory examination, head CT
    scan
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR :46 x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP :110/ 60 mmHg, HR :68 x/minute, regular, adequate

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

    E: T (ax) : 37,1 oC
    Secondary Survey
    Both orbital region :
    I : Seen edema(+), hematoma(+), in both superior
    palpebrae, wound (-), excoriation (-), active
    bleeding(-), deformity (-)
    P : Tenderness (+), Crepitating (-)

    Right parietal region :


    I : Seen edema (+), hematome (+), bleeding (+)
    excoriation (+) in right cheek, deformity (-)
    P: Tenderness (+), Crepitating (-)
    Laboratory Result
    WBC : 13,0 x 103 / L

    RBC : 4,76 x 106 / L

    HGB : 10,8 g/dL

    HCT : 33,6%

    PLT : 167 x103/ L

    Blood Sugar : 146 mg/dl

    Ureum : 38 mg/dl

    Creatinin : 1, 00 mg/dl

    GOT / GPT : 34/ 32 /L


    SKULL X-RAY
    Head CT Scan
    WORKING DIAGNOSIS : Mild head injury GCS 15 (E4M6V5)
    Dentoalveolar fracture
    Multiple excoriation

    MANAGEMENT : O2
    Medicaments
    Report to senior neurosurgeon
    advice : conservative
    Report to senior plastic surgeon
    Advice : plan for elective surgery
    PROGNOSIS : Good

    FOLLOW UP : Vital sign


    No.5
    Name : Mrs. S Sex : female
    Age : 30 years old No. Reg : 651540

    Chief complaint : Wound on upper lips and bloody nose


    History Taking : The condition had been apparent for 30 minutes before
    the patient admitted to the hospital due to traffic
    accident, there were pain, and and bloody nose.
    Mechanism of : She was riding motorcyle when suddenly bus in front of
    injury him stooped, then she hit the bus and bumped her face
    to the bus and asphalt
    Sustained injury : Lips, nose
    Symptom & sign : Wound
    Examination : Physical examination
    PHYSICAL EXAMINATION
    Primary Survey
    A: Clear

    B: RR : 16x/minutes, spontaneous, symmetric, thoraco


    abdominal type

    C: BP : 110/60 mmHg, PR : 80x/minute, regular, adequate

    D: GCS 15 (E4M6V5), pupil equal 2,5 /2,5 mm, Light Reflex


    +/+, all motoric muscle function are normal
    E: T (ax) : 37,1 oC
    Secondary Survey
    Regio dorsum pedis dextra :
    I : Seen lacerated wound size 1x0,5 cm. Edema
    (+) in upper lips
    P : Tenderness (+), Crepitation (-)
    WORKING DIAGNOSIS : - Vulnus laceratum at upper lips
    - Epistaxis

    MANAGEMENT : Medicament
    Proceed Wound Care
    Patient discharge
    THANK YOU

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