Emergency Case Report

2014, 8-9 TH December

Resident on Duty : dr. Alma Wijaya

Chief Co-Assistant : Bimo Harmaji
Team :
Endah, Erina, Mira, Firdha, Dyah, Ady

Minor Surgery

:-

Digestive Surgery

: 1

Thorax Cardiovascular Surgery

:-

Plastic Surgery

:1

Urology Surgery

Neurosurgery

: 2

Pediatric Surgery

: 1

Oncology Surgery

Orthopaedy

Total

No

Identity

Indah Nuraini/
19 y.o/
1.13.11.08

Admission
to E.R.

Diagnosis

Treatment / Planning

IVFD resucitation 110/70 N

Hypovolemic shock rapid Oksigenation
response + Obs blunt
Consul digestif surgery
abdominal trauma with
Advice : Resusitation
susp spleenic rupture +
Pro LE damage control
8th
December
sup hepatic rupture
surgery, Transfusion preparation
2014/ 05.00 Severe Head Injury GCS 8
Preparing for USG if
stable condition
p.m
dd secondary Brain Injury
+ closed fracture of the -Consul Neurosurgery
Advice : Resusitation
right femur midle third
CT brain contusion agree
transverse displaced
for damage control
Co Orthopaedic :
Apply skin traction
ORIF elective

No

Identity

An. Rahman/ 8
month old/
1.13.11.22

Admission
to E.R.

8th
December
2014/ 10.00
p.m

Diagnosis

Treatment / Planning

Obstructive Ileus high

level due to ? Dd ileus
due to electrolit imbalance
with hiperkalemia,
hiponatremia and anemia

IVFD moderate rehidration

Decompression
Antibiotic
H2 blocker
Co pediatric Surgery :
General condition improvement
Join care with pediatric dept

No

Identity

An Imron Rofiq
13 y.o/
1.13.11.21

Admission
to E.R.

2014, 8TH
December/
10.30 p.m

Diagnosis

Moderate head Injury

GCS 13 E3M6V4 +
cerebral edema

Treatment / Planning

Consul neurosurgery :
Konserfative treatment
- IVFD NS maintenance
- Antibiotic
- Analgesic
- H2 Blocker
- GCS observation

No

Identity

Tn Horman 53
y.o/ 1.13.11.25

Admission
to E.R.

2014, 8TH
December/
11.30 p.m

Diagnosis

Haemorhagic stroke With

ICH 12cc ar thalamus +
IVH

Treatment / Planning

Consul neurosurgery :
-Pro Observation GCS and vital sign
-IVFD NS 30 tpm
-Analgetic
Antiemetic
Antihipertensive agent

No

Identity

Tn Tendix Vega
Ariyanto/ 21
y.o/ 1.13.11.27

Admission
to E.R.

2014, 9TH
December/
01.30 a.m

Diagnosis

Fraktur of the right

parasymphisis mandibula

Treatment / Planning

Consul plasticsurgery :
-IVFD RL Maintenance
Antibiotic
Analgesic
H2 blocker
Anti Fibrinolitic
Pro Re Hecting
Pro Orif Platin Elective
Beeding tamponade
Oral hygene

1. Ms. Indah Nuraini/ 19 y.o/ 1.13.11.08

5th December 2014/ 05.00 p.m
Chief Complain : Unconsious
History:
2,5 hours ago before admission, the patient had an accident . The patient was,
riding a motorcycle at high speed and hit the truck. The patient lossing her
balance and suddenly hit stopped the truck. The patient was throwm, with head,
stomatch and right foot hit truck body. After the incident, patient was taken to ER
Pelaihari by citizen around. Patient got 2 kolf PRC at ER Pelaihari.
Because the complain patient in Pelaihari Hospital, patient referred to Ulin
General Hospital for further treatment.

Primary Survey
A

Clear

Clear, RR= 22 bpm, symmetric

respiratory movement, symmetric
VBS

BP : 70/50 mmHg
Pulse rate : 128 bpm, reguler,
weak lifted, CRT < 2 sec.

GCS E2V5M2, round and equal

pupils diameter (3mm/3mm), light
reflexes (+/+), no paralysis

IVFD 1L

9-10 hour before

admission

On the road

Physical examination
Head/Neck

Chest

Abdomen

Extremities

Eyes : anemic conjunctiva, icteric sclera (-),

Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
I : Injury + at RUQ and LUQ
A : Bowel sound (+)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness + DM +
P : Tymphani

Cold acral localize at right femur , no parese

Rectal Toucher
Anal sphingter : strong
ampulla was not collapse
Smooth mucous
Blood -

Clinical Picture Local Status

Hematom at right frontal

region

Clinical Picture Local Status

Excoriation wound at upper

left region, upper right region
DM +

L : edema + deformity +
F : False movement +
M : Limited

Laboratory
Hb 6.9 g/dl
Leukosit 20900/ul
Eritrosit 320/ul

Hasil PT : 22.3 detik

Hct 21,7%

Control normal PT : 11,4

Trombosit 235000/ul

Natrium : 140.3 mmol/l

RDW-CV 16.1%

Kalium : 3.8 mmol/l

SGOT/PT 640/235 U/I

Chlorida : 105.4 mmol/l

Working Diagnosis
Hypovolemic shock rapid response + Obs blunt abdominal trauma with
susp spleenic rupture + susp hepatic rupture + Severe Head Injury GCS
8 dd secondary Brain Injury + closed fracture of the right femur midle
third transverse displaced

Management
IVFD resucitation 110/80
Oksigenation
Vital sign Observation
Consul digestif surgery
Advice : Resusitation
Pro LE damage control surgery, Transfusion preparation
Preparing for USG if stable condition
-Consul Neurosurgery
Advice : Resusitation
CT brain contusion agree for damage control
Co Orthopaedic :
Apply skin traction
ORIF elective

2. An M. Rachmani/ 8 m.o/ 1.13.11.22

8th December 2014/ 10.00 p.m
Chief Complain : unable to defecation
History:

Since 2 days before hospital admission patient been complained couldnt defecation and
flatus. The patient got vomit 3 days before hospital admisson. The vomit was food contained
. The patient also got diarhea 6 days before admission, the componet secret and contain
mucous. History of fever history of passage abnormality before - The patient hasnt history
of late of meconium. The patient was first child. The weight was 2800 gr. Patient always
control ANC regularly and got all of imunitation.
Because the complain patient in Pelaihari Hospital, patient referred to Ulin General Hospital
for further treatment. Because his complain patient referred to Ulin General Hospital for
further treatment.

Physical Examination
Conciousness : Compos Mentis
Vital sign :
HR = 120bpm
RR = 38 bpm
T = 36,8C

Physical Examination

Head/Neck

Chest

Abdomen

Extremities

Eyes : anemic conjunctiva - , icteric sclera (-), sunken eye +

Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
I : look distended +
A : Bowel sound decreased, metalic sound +
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-), DM P : Tymphani

Warm, no oedema, no parese

Physical Examination
Rectal toucher :
- Strong TSA
- Colaps ampula
- Mass (-)
- Feces (-)
- Mucous (-)
- Blood (-)
- Rectal tube insertion no fecal content

Clinical Picture Local Status

Clinical Picture Local Status

Abd AP

Laboratory

Hb 8.8 g/dl
Leucocyte 10600 /l
Hematocrit 27,9 vol%
Trombocyte 823000/ l
SGOT/SGPT 44/13 U/l
Ur/cr 47/0.5 mg/dL
Na/K/Cl 125,1/6,1/91,6 mmol/l

Working Diagnosis
Obstructive Ileus high level due to ? Dd
ileus due to electrolit imbalance with
hiperkalemia, hiponatremia and anemia

Management

IVFD moderate rehidration

Decompression
Antibiotic
H2 blocker
Co pediatric Surgery :
General condition improvement
Join care with pediatric dept

3. An Imron Rofiq/ 13 y.o/ 1.13.07.96

2014, 8TH December/06.30 p.m

Chief Complain: decrease of concious

History : 8 hours before admission, his friend and the patient
drive motorcycle together, suddenly the patient lost control and
balance, the patient drop up to the ground and his head hit the
road. Then the patient was taken to the ER primary health care
in Kapuas, the patient didnt got primary survey adequately and
then referred to Ulin General Hospital for further treatment.

Primary Survey
A

Clear, Snoring (-), gurgling (-),

Clear, RR= 28 bpm, symmetric

respiratory movement, symmetric
VBS

Pulse rate : 108 bpm, reguler,

strong lifted, CRT >2 sec.
GCS E3V3M5, round and equal
pupils diameter (3mm/3m), light
reflexes (+/+), no paralysis

IVFD, Wound
toillete
-

P
L
E

8 hours before
admission
Road

Secondary survey
Eye : Anemic conj. (-/-), icteric sclera (-/-), oedem (+)
localize
Mouth : wet mucous
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

Head/Neck

Chest

I : Symmetric respiratory movement, retraction (-)

P : Symmetric VF
P : Sonor in all lung field
A : Symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen

I : Wound (-), distension (-), hematoma (-)

A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).
P : Tympanic in all quadrants

Extremities

Warm, edema (-), paralysis (-)

Wound (+)

Clinical Picture Local Status

Multiple excoriation +
Racoon eye
Battle sign
Ottorhagia
Rinnorhagia -

Laboratory

Hb 12.2 g/dl
Leucocyte 12200/l
Hematocrit 36.3 vol%
Trombocyte 237000/ l
SGOT/SGPT 54/22U/l
Ur/Cr 27/0.7 mg/dL
Na/K/Cl 140,5/4,1/105,0
mmol/l

Working Diagnosis
Moderate head Injury GCS 13 E3M6V4 + cerebral edema

Management

Consul neurosurgery :

Konserfative treatment
- IVFD NS maintenance
- Oksigenation
- Antibiotic
- Analgesic
- H2 Blocker
- GCS observation

4. Tn Horman/ 53 y.o/ 1.13.11.25

8th December 2014/ 11.30 p.m
Chief Complain : Severe Headache
History:
Since 2 days ago before admission, the patient got severe headache. The pain
not lost with treatment (drug) . The patient also complained vomit and weakness
left extremite. History of seizure -. The patient hipertension history.
Because the complain patient in Sampit Hospital, patient referred to Ulin General
Hospital for further treatment.

Physical Examination
Conciousness : Compos Mentis
Vital sign :
HR = 110 bpm
RR = 36,5 bpm
T = 36,8C
BP = 180/90 mmhg

Physical Examination

Head/Neck

Chest

Abdomen

Extremities

Eyes : anemic conjunctiva, icteric sclera (-),

Nose : No epistaxis
Mouth : Wet mucosa
Neck : Lymph nodes enlargement (-), JVP enhancement (-)

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
P : Sonor at all lung fields
A : Symmetric VBS, no rhonchi, no wheezing
I : Inguinal lymph nodes enlargment (-)
A : Bowel sound (+)
P : soeple, Liver/spleen/kidney not palpable, mass not palpable,
tenderness (-),
P : Tymphani

Warm, no oedema
5 2
5 2

Clinical Pictures

Laboratorium
Hb 15,0 mg/dl
Hematokrit 41,0 vol%
Leukosit 9800 ul
Trombosit 213.000 ul
GDS 144 mg/dl
SGOT/SGPT 18/13 UI/L
Ureum/Kreatinin 28/1,9 mg/dl

Working Diagnosis
Haemorhagic stroke With ICH 12cc ar thalamus + IVH

Management
Consul neurosurgery :
-Pro Observation GCS and vital sign
-IVFD NS 30 tpm
-Analgetic
Antiemetic
Antihipertensive agent

5. Tn Tendix Vega/ 21 y.o/ 1.13.11.27

9th December 2014/ 01.40 a.m
Chief Complain : lower jaw pain
History:
Since 2 hours ago before admission, the patient when drive a motorcycle,
suddenly he lost balance and control. The patient fall, his chin hit the road. The
patient complained pain at his lower jaw. He cant open his mouth and bleeding
from his mouth. History of fainted Bleeding from ear and nose Because the complain patient in RSUD Banjarbaru Hospital, patient referred to
Ulin General Hospital for further treatment.

Primary Survey
A

Clear, Snoring (-), gurgling (-),

Clear, RR= 22 bpm, symmetric

respiratory movement, symmetric
VBS

Pulse rate : 92 bpm, reguler, strong

lifted, CRT >2 sec.
GCS E4V5M6, round and equal
pupils diameter (3mm/3m), light
reflexes (+/+), no paralysis

Antibiotic,
Analgesic,
Antifibrinolitic
-

P
L
E

2 hours before
admission
Road

Secondary survey
Eye : Anemic conj. (-/-), icteric sclera (-/-), racoon eye
(-/-)
Mouth : wet mucous, step defect (+), mandibula :
unstable, bleeding (+)
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

Head/Neck

Chest

I : Symmetric respiratory movement, retraction (-)

P : Symmetric VF
P : Sonor in all lung field
A : Symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen

I : Wound (-), distension (-), hematoma (-)

A : Normal bowel sound
P : H/L/M not palpable, tenderness (-).
P : Tympanic in all quadrants

Extremities

Warm, edema (-), paralysis (-)

Wound (+)

Laboratory

Hb 14,8 g/dl
Leucocyte 16700/l
Hematocrit 41.9 vol%
Trombocyte 186000/ l
Hasil PT 14,2 detik
Hasil APTT 25,2 detik
SGOT/SGPT 115/46 U/I

Open wound 6cm in length,

irreguler edge base on bone

Working diagnosis
Fraktur of the right parasymphisis mandibula

Management
Consul plastic surgery :
-IVFD RL Maintenance
Antibiotic
Analgesic
H2 blocker
Anti Fibrinolitic
Pro Re Hecting
Pro Orif Platin Elective
Beeding tamponade
Oral hygene

TERIMAKASIH