EMERGENCY CASE REPORTS

Saturday, Pebruari 19 th , 2011

SURGERY DEPARTMENT

RS. Wahidin Sudirohusodo

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
EMERGENCY CASE REPORT
Saturday, Pebruary 19 th 2011

Ambulation : patient
Hospitalized : patients
Observation : patients
Operated : patient
Death : patient
patient
Total :
s

WAHIDIN SUDIROHUSODO HOSPITAL

MAKASSAR
No. 1
Name : Mr. Ilhamdi Sex Male
Age : 16 years old MR 45 79 80

Chief : Headache
complain
History taking : Suffered since 8 hours before admitted to ER due to traffic
accident. History loss of consciousness (+), vomiting (-).
Mechanism of : He was ride a motorcycle suddenly he felt down with his bumped
injury to asphalt.

Injury sustain : Head

Symptom & : Wound and pain

sign
Examination : Physical examination, Chest X-Ray, Head CT-Scan
 Primary Survey
A: Clear, no obstruction.
B: RR : 20 x/mnt, spontaneous, symmetric, and
thoraco abdominal type.

C: BP : 110/80 mmHg, Pulse : 100 x/mnt, adequate, regular.

D: GCS 15 (E4M6V5), pupil equal 2,5 mm/2,5 mm, LR +/+

E: T : 36.5C
Secondary Survey
Right Frontal Region
I: Seen 3 stiched wound size 5 cm, 3 cm, and 2 cm. swelling (+),
hematoma (-).
P: Tenderness (+)
Right Orbita Region
I: Seen swelling (+), hematoma (+).
P: Tenderness (+)
Right Maxilla Region
I: Seen stiched wound size 4 cm swelling (+), hematoma (-).
P: Tenderness (+)
Secondary Survey
Nasal Region
I: Seen stitched wound size 2 cm, swelling (+).
P: Tenderness (+)

Labialis Superior Region

I: Seen swelling (+).
P: Tenderness (+)
Laboratory Result
WBC : x 103 / L PT : 6

RBC : x 106 / L APTT : 8

HGB : g/dL HbsAg : Negative

HCT : %

PLT : x 103 / L

CT / BT : 30 /30

Blood Sugar : mg/dl

Ureum : mg/dl

Creatinin : mg/dl

SGOT/SGPT : / u/l
Skull AP and Lateral
X-Ray Waters Position
Cervical X-Ray
Thorax X-ray
Facial CT-Scan
Facial CT-Scan
WORKING DIAGNOSIS Mild Head Trauma GCS 15 (E4M6V5)
Maxilofacial injury

MANAGEMENT :O2
IV FD
Medicaments
-Report to senior plastic surgeon advice ORIF

PROGNOSIS Good
FOLLOW UP Vital sign