EMERGENCY CASE REPORTS

Saturday, July 25th 2015

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
 Saturday , July 25th 2015

Ambulation : 2 Patients

Hospitalized : 2 patients

Observation : Patients
Operated : Patients
Death : Patient

Total : 4 patients
No. 1
Name : Mr. A Sex : Male
Age : 50 years No. Reg : 720004

Chief complaint : Wound at face

History taking : This condition has been apparent for 30 minutes before
admitted to the hospital due to traffic accident. History
loss of consciousness (-) nausea (-) vomiting (-).
Mechanism of : He was parked his motor at side of street when
injury suddenly a minivan hit him. He throwed with his face
bumped to his motorcycle.
Injury sustain : Head, face
Symptom & sign : Headache
Examination : Physical examination, laboratory examination, skull,
waters, CT scan 3D facial
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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

abdominal type

C: BP :140/70 mmHg, HR : 88 x/minute, regular, adequate

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

E: T (ax) : 36,9 oC
Secondary Survey
Left orbita region :
I : Seen edema(+), hematoma(+), active bleeding (-)
P : Tenderness (+), Crepitating (-)
Left zygoma region :
I : seen edema (+), no hematome, no active bleeding
P : tenderness (+), Crepitating (+)
 Laboratory Result
WBC : 10,2 x 103 / L

RBC : 4,53 x 106 / L

HGB : 10,2 g/dL

HCT : 30 %

PLT : 215 x103/ L

CT / BT : 800 / 3 00

Blood Sugar : 193 mg/dl

Ureum : 25 mg/dl

Creatinin : 1,14 mg/dl

GOT / GPT : 120 / 68 /L

Skull X-Ray
Waters
WORKING DIAGNOSIS : Maxillofacial injury + fracture left zygoma
bone

MANAGEMENT : O2
Medicaments
Report to senior plasticsurgeon
advice : CT Scan 3D Facial plan for ORIF
electively but family refused treatment
No. 2
Name : Mrs. A Sex : Female
Age : 62 years No. Reg : 719801

Chief complaint : Decrease of consciousness

History taking : This condition has been apparent for 8 hours before
admitted to the hospital due to head injury. History of
vomiting (-) nausea (-) convulsion (-). Prior medicament
was in Takalar Hospital
Mechanism of : She was on her way to accros street , when suddenly a
injury motorcycle hit her. She fell down with his head bumped
to asphalt
Injury sustain : Head, face
Symptom & sign : Decrease consciousness
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 :130/ 80 mmHg, HR :80 x/minute, regular, adequate

D: GCS 11 (E3 M5 V3), pupil equal 2,5 /2,5 mm , LR +/+

E: T (ax) : 37,1 oC
Secondary Survey
Left occuli region :
I : Seen edema(+), hematoma(+), active bleeding (-)
P : Tenderness (+), Crepitating (-)
Right frontalis region :
I : seen exoriated wound size 2 x 0.7 cm
 Laboratory Result
WBC : 12,6 x 103 / L

RBC : 3,53 x 106 / L

HGB : 10,2 g/dL

HCT : 30 %

PLT : 215 x103/ L

CT / BT : 800 / 3 00

Blood Sugar : 193 mg/dl

Ureum : 25 mg/dl

Creatinin : 1,14 mg/dl

GOT / GPT : 60 / 38 /L
Head CT Scan
WORKING DIAGNOSIS : Traumatic Brain Injury injury GCS 11
(E3M5V3)
ICH right temporo parietal region
Contutio cerebri at left temporo parietal
region
SAH at right parietal region
Edema cerebri
Subgaleal hematom at letf parietal region
MANAGEMENT : O2
Medicaments
Report to senior neurosurgeon
advice : conservative

PROGNOSIS : Dubia
No. 3
Name : Mr. Mundus Sex : Male
Age : 40 years old No. Reg : 719987

Chief complaint : Wound at the face

History taking : Suffered since 30 minutes before admitted to the
hospital due to traffic accident. History loss of
consciousness (-) vomiting (-), convulsion (-).
Mechanism of : He was passenger a motorcycle suddenly feel down
injury because drowsiness and he not using a helmet and than
his head bumped to the asphalt

Injury sustain : Head, face, pelvis

Symptom & sign : Headache
Examination : Physical examination
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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

abdominal type

C: BP :120/ 70 mmHg, HR :84 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

Right temporofrontal region :

I : Seen lacerated wound size 3 x 0,5 cm, edema(+), hematoma(+),
wound (-), active bleeding(-), deformity (-)
P : Tenderness (+), Crepitating (-)
WORKING DIAGNOSIS : Excoriated wound at regio frontalis

MANAGEMENT : O2
Medicaments
Wound care

PROGNOSIS : Good

FOLLOW UP : Vital sign