Emergency Report

Friday, April 11th, 2014

Beriman Parhusip, dr

Attendings On Duty
Pediatric surgery: dr. Irhamni, SpB, SpBA Digestive surgery: dr. T. Suhardi, SpB-KBD Orthopaedic surgery: dr. H. Satria, SpOT(K) Plastic surgery: dr. Asrofi, SpB, SpBP Neurologic surgery: dr. H. Setiajaya, SpBS Oncologic surgery: dr. D. Hangesti, SpB-Onk Thorax CV Surgery: dr. W. Hadi, SpB, SpBTKV Urologic surgery: dr. Hariyono, SpU

Patient Distribution
Out Patient : 0 In patient : 0 Operations : 2

1. Mrs Refi, 22 y.o

Admission : 11-4-14; 11.30 a.m/MR 434603 CC : pain at whole abdomen HT : Since 2 days prior to admission, she felt pain at whole abdomen. The pain was initially felt at lower abdomen and then spread to whole abdomen, continually, and became worse, followed by undefecating, nausea (+), vomiting (-), fever(+). History of late menstruation (-), trauma (-). History of leuchorrhea (+). There was no complaint in urination.

Physical Examination
General Status :
Alert BP : 80/60 RL 1500 cc 110/70 mmHg PR :120 x/mnt RR : 24 x/mnt T : 37,0 0C Conjuntivas were anemic (+)

Local Status :
At abdomen : distention, tense, bowel sound (+), tenderness (+), rebound tenderness (+), muscular rigidity (+), mass (-) DRE : normal sphincter tone, smooth mucosa, ampulla was collapsed, mass (-), tenderness at all direction Glove : stool (+), blood (-)

Jenis Pemeriksaan (Hematologi)

SGOT SGPT Ureum

Hasil
15 10 54

Nilai Rujukan
< 35 U/L <40 U/L 20 50 mg/dL

Kreatinin GDS
Na K Cl

2,1 148
130 4,2 98

0,5 1,5 mg/dL <140 mg/dL

135-147 mmol/L 3,5 5,0 mmol/L 95 105mmol/L

Laboratory Finding
Hb : 9.5 gr/dL Ht : 28 % WBC : 19.000 /mm3 Plt : 419.000 /mm3 AST : 15 U/L ALT : 10 U/L Na : 130 mmol/L K : 4.2 mmol/L Ur : 54 mg/dL Kr : 2.1mg/dL Glucose : 271 mg/dL PT : 11.7 sec (control 13,5) aPTT : 30 sec (control 30,5)

PP test : negatif

WD/
Diffused peritonitis due to suspect tuboovarial abcess rupture DD/ mesenterial trombosis Sepsis

T/
NPO Infusion RL 2000 cc NGT and urine catheter insertion Antibiotic Analgetic Consult to obgyn Laparotomy exploration

Obgyn consult
There were no deviation in obstetri and gynecology departement

Intraoperative finding
We found :
Reddish peritoneal fluid 500 cc Potruded a loop of ileum through mesoileal at 40 cm proximal to valvula Bauhini that caused ileal strangulation Ileal strangulated 180 cm Remaining intestine 190 cm (160 cm from lig. Treitz + 30 cm from v. Bauhini) Organ solid within normal limit Ovarium and tuba within normal limit
Intraoperative consult : none Blood lost : 50 cc Histophatology examination : none

Post Op diagnosis : Diffused peritonitis due to ileal strangulation due to mesoileal hernia Sepsis Treatment : Segmental ileal resection and ileoileal end to end anastomosis

Intraoperative Pictures

2. Mrs, A. , 16 y.o
Admission : 11-4-14; 23.00 p.m/ MR 434194

CC : pain at left upper leg and wound at perineal region HT : 6 hours prior to admission, when she was in the riding car with high velocity at Jagorawi toll road, without seat belt, the car hit the left side of limiting road bar, caused she got out of the car. The mechanism of injury was unknown. History of loss of uncousiousness (-), vomiting (-), no bleeding from ears, nose or mouth. She felt of pain at her left upper leg and wound at perineal region. The patient was brought to Bhayangkara Hospital, and then referred to Gatot Subroto Hospital.

Primary Survey :
A : clear B : RR = 22x, symmetrical chest expansion, equal VBS C : BP = 110/80 PR = 92x/m D : GCS = 15, isochore pupils, 3/3 mm, LR +/+. Motoric parese -/-

Secondary Survey : Left facialis : excoriation (+), hematoma (-) Thorax : bruise (-) Abdomen : bruise (+), flat, bowel sound (+) normal, tenderness (-) Pelvic : bruise (-) Perianal : vulnus (+) 2x2 cm, at 1 oclock direction, 1 cm from anal verge direct to left major labium. External sphincter muscle was intact At left femur region : wound (-), deformity (+), tenderness (+), ROM limited due to pain

Pelvic and femur X-rays

FAST
There were no fluids collection at hepatorenal space, splenorenal space, or retrovesica space

Laboratory Finding
Hb Ht WBC Plt AST ALT : 8.8 gr/dL : 27 % : 21.700 /mm3 : 433.000 /mm3 : 177 U/L : 99 U/L

Ur Kr
Na K

: 37 mg/dL : 0.8 mg/dL

: 135 mmol/L : 3.7 mmol/L

Glucose

: 159 mg/dL

WD/ Closed fracture of left shaft femur at middle third, oblique displaced Lacerated wound at perianal region Anemia due to haemorrhagic
T/ Antibiotic and analgetic Orthopedic : skin traction ORIF Pediatric surgery : wound care debridement + primary suture

Intraoperative found
Orthopedic:
Hematoma (+) 300 cc Fracture of middle third of left femur, oblique displaced

Pediatric :
Wound at perianal region 2x2 cm, at 1 oclock direction, 1 cm from anal verge to left major labium Rupture of subcutaneus part of external sphinter muscle

Blood lost : 100 cm Intraoperative consultation : none Histophatology examination : none

Intraoperative pictures

Thank You