Tuesday, March 4th , 2014

Ambulation : patient
Hospitalized : 4 patients
Observation : 1 patient
Operated : 3 patient
Death : patient
Total : 4 patients
No. 1
Name : Mr. H Sex : Male
Age : 31 years old No. Reg : 653569

Main complaint : Stab wound

History taking : The condition had been apparent since 2 hours before
the patient was taken to the hospital due to fighting.
Prior medical care at Daya Hospital.

Mechanism of : The patient was drunk with his friends and suddenly they
injury were fighting. He got stab by his friend

Sustained Injury : Back , flank

Symptom & sign : Stab Wound
Examination : Physical examination, Chest X-Ray, USG abdomen, CT
done Scan Abdomen
PHYSICAL EXAMINATION

Primary Survey
A: Clear

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

abdominal type

C: BP :130/ 80 mmHg, HR :88 x/minute, regular, adequate

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

+/+
E: T (ax) : 36,7 oC
Secondary Survey

Abdomen:
I : Seen Flat, seen scar post laparotomy, skin
colour same with vicinity, darm countour (-),
darm steifung (-)
A : Peristaltic (+)
P: Tenderness (-), Defans (-)
P : Tympani
Secondary Survey
Left Suprascapula Region :
I : Seen stabbed wound size 5x2 cm,edema (-),
hematoma (-), active bleeding (-)
P: Tenderness (+), crepitation (-)

Right Flank Region :

I : Seen stabbed wound size 4x2 cm,edema (-),
hematoma (-), active bleeding (-)
P: Tenderness (+)

Digital Rectal Examination:

Sfingter tone was tight
Mucous was smooth
Ampulla fill with feces
Handschoen : blood (+), slime (-), feces (+)
 Laboratory Result Urinalisa
WBC : 22,4 x 103 / L Blood: 200
RBC : 5,59 x 106 / L Leukosit: +++
HGB : 16,2 g/dL Erytrocite: ++
HCT : 48 %

PLT : 400 x 103/ L

CT / BT : 800 / 200

Blood Sugar : 144 mg/dl

Ureum : 18mg/dl
Creatinin : 0,8 mg/dl
GOT / GPT : 24 / 29 /L
Chest X-Ray
USG
Abdomen CT scan
WORKING DIAGNOSE. : Generalized Peritonitis ec susp hollow
viscus perforation ec v.ictum penetrans
Laceration of the right kidney

MANAGEMENT Medicaments
Report to Senior Digestif surgeon,
advice : Laparotomy exploration
Consult to senior urology surgeon, advice:
Laparotomi exploration
 Operating Procedure
1. Patient laid supine under GA
2. Asepsis and draping procedure
3. Perform midline incision and deepen shark and
blunt
4. Open the peritoneum, seen blood 500cc, the
evacuate the blood
5. Identification the retroperitoneal organ
6. Seen perirenal hematoma, evacuate hematoma.
Seen lacerate on the right kidney grade IIIA,
decided to do renoraphi
7. Control the bleeding
7. Stitch wound layer by layer
8. Done
WORKING POST : Generalized Peritonitis due to v.ictum
DIAGNOSIS penetrans
Gastric perforation of pyloric
Ascenden colon perforation
Laceration of the kidney gr. III

PROGNOSIS : Fair

FOLLOW UP Vital Sign

Acute Abdomen
Fluid Balance
No. 2
Name : Mr. I.P Sex : Male
Age : 15 years old No. Reg : 653391

Chief complaint : Headache

History taking : The condition had been apparent since 1 hour before
admitted to the hospital due to traffic accident. There were
history of vomiting, unconsciousness and no seizure. Prior
medical Daya hospital.

Mechanism of : He was riding a motorcycle then suddenly a truck hit from

injury his side then he fell down with his right head and shoulder
bumped to the asphalt. He used a helmet

Injury sustain : Head and Right shoulder

Symptom & sign : Headache

Examination : Physical examination, laboratory examination, head CT

scan, Thorax X ray,
PHYSICAL EXAMINATION

Primary Survey

A: Clear

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

type

C: BP : 120/80 mmHg, HR : 86 x/minute, regular, adequate

D: GCS 12 ( E3M5V4 ), pupil equal 2,5/2,5mm , LR +/+

E: T (ax) : 36,8 oC
Secondary Survey

Left Auricula :
I : Seen bloody otorrhea, hematoma (-)
P: Tenderness (+), crepitation (-)

Right Shoulder :
I : Seen hematoma size 8x7cm,
edema (+)
P: Tenderness(+), crepitation(-), thrill (-)
Laboratory Result
WBC : 28,5 x 103 / L
RBC : 3,47 x 106 / L
HGB : 10 g/dL
HCT : 30,8 %

PLT : 332 x 103/ L

CT / BT : 600 / 200

Blood Sugar : 211 mg/dl

Ureum : 30 mg/dl
Creatinin : 0,8 mg/dl
GOT / GPT : 55 / 28 /L
Head CT Scan
Thorax x-ray
WORKING : Moderate Head injury GCS 12 (E3M5V4)
DIAGNOSIS EDH at Left Temporal

: O2
IVFD
Medicaments
Report to senior neurosurgeon
advice : Craniectomy
 Operating Procedure
1. Patient laid supine under GA
2. Disinfectant and draping procedure
3. Perform horse shoe incision, depend until
periosteum
4. Perform 3 burr hole, continue craniotomy with
giggly saw, continue with hang Dura
5. Seen hematoma 20cc, evacuate hematoma,
control the bleeding
6. Clean the wound
7. Stitch wound layer by layer with 1 vacum drain
8. Done
WORKING POST : Moderate Head injury GCS 12 (E3M5V4)
DIAGNOSIS EDH at Left Temporal

PROGNOSIS : Good

FOLLOW UP Vital Sign

GCS
No. 3
Name : Mr. S Sex : Male
Age : 40 years old No. Reg : 653571

Chief complaint : Pain of the face

History taking : The condition had been apparent since 9 hours before
admitted to the hospital due to traffic accident. There
were no history of vomiting, unconsciousness and
seizure. Prior medical care at Soppeng hospital.
Mechanism of : He was riding a motorcycle. Suddenly another
injury motorcycle struck him from opponent direction. He fell
down with his face bumped to the asphalt. He used a
helmet.
Injury sustain : Face
Symptom & sign : Pain, wound
Examination : Physical examination, laboratory examination, skull x ray
PHYSICAL EXAMINATION
Primary Survey
A: Clear

B: RR : 22 x/minutes, spontaneous, symmetric,

thoracoabdominal type

C: BP : 130/80 mmHg, HR : 90x/minute, regular,

adequate
D: GCS 15 ( E4M6V5 ), pupil equal 3/3mm , LR +/+

E: T (ax) : 36,2oC
Secondary Survey
Right Zygoma Maxila Region :
I : Seen edema (+), hematoma (+)
P : Tenderness (+), crepitating (+)

Left Zygoma Maxila Region :

I : Seen edema (+), hematoma (+)
P : Tenderness (+), crepitating (+)

Mandibula Region :
I : deformities (+), hematoma (+)
P : Tenderness (+), crepitating (+)

Lateral Nasal Region :

I : Deformitas (+), hematoma (-)
P : Tenderness (+), crepitating (-)
 Laboratory Result
WBC : 19,2 x 103 / L

RBC : 4,04x 106 / L

HGB : 11,4 g/dL

HCT : 33,3 %

PLT : 311 x 103/ L

CT / BT : 600 / 300

Blood Sugar : 117 mg/dl

Ureum : 30 mg/dl

Creatinin : 0,70 mg/dl

GOT / GPT : 29 / 20 /L
Skull AP/ Lateral
WORKING : Maxilo facial Injury
DIAGNOSIS Multiple Panfacial fracture

MANAGEMENT : O2
IVFD
Medicaments
Report to senior plastic surgeon
advice : Plan for ORIF
 Operation Procedure
Patient laid supine under GA
Disinfection and draping procedure
Perform submucosal incision, seen fracture of parasimphysis
mandible fixation with miniplate 4 hole and 4 screw
Perform right and left subcilier incision, deepen until osteum,
seen line fracture at zygoma fixation with miniplate 3 hole
and 3 screw
Perform reposition nasal fracture and insert 1 sheet silicon.
Insert 1 right nasal tampon
Stitch operation wound layer by layer
Done
POST OP : Maxilofacial Injury
DIAGNOSIS Multiple Panfacial Fracture

PROGNOSIS : GOOD

Vital sign
FOLLOW UP
Wound healing
No.
Name : Mrs. J Sex : Female
Age : 24 years old No. Reg : 653449

Chief complaint : Decreased of consciousness

History taking : The condition had been apparent since 6 hours before
admitted to the hospital due to traffic accident. There
were no history of vomiting and seizure. Prior medical
Maros hospital.
Mechanism of : She was a passenger of a car. Suddenly hit a tree. The
injury next mechanism is unclear. She found inside the car in
unconsciousness condition.

Injury sustain : Head

Symptom & sign : Decreased of consciousness
Examination : Physical examination, laboratory examination, head CT
scan, Cervical X-Ray, Thorax X-Ray
PHYSICAL EXAMINATION
Primary Survey
A: Clear

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

thoracoabdominal type

C: BP : 130/70 mmHg, HR : 76 x/minute, regular,

adequate
D: GCS 11 ( E3M5V3), pupil equal 2,5/2,5mm , LR +/+

E: T (ax) : 36,8 oC
Secondary Survey
Left Frontal Region :
I : Seen lacerated wound size 5x2cm,
edema (-), hematoma (-), active
bleeding (-), bone exposed (+)
P: Tenderness difficult to evaluate,
crepitation (-)
Laboratory Result
WBC : 15,9 x 103 / L
RBC : 4,11 x 106 / L
HGB : 11,9 g/dL
HCT : 36,2 %

PLT : 278 x 103/ L

CT / BT : 700 / 300

Blood Sugar : 194 mg/dl

Ureum : 22 mg/dl
Creatinin : 0,7 mg/dl
GOT / GPT : 117 / 132 /L
Head CT Scan
Thorax X-Ray
WORKING : Moderate Head injury GCS 11 (E3M5V3)
DIAGNOSIS Linear Fracture at Left Frontal bone
ICH at right temporal region

MANAGEMENT : O2
IVFD
Medicaments
Report to senior neurosurgeon
advice : Conservative + Wound Care

FOLLOW UP : Vital Sign

GCS
 Semester I
Makalah I
Makalah II
Semester IV
Stase 8 Sub Bagian

Makalah III
(Nasional)

Makalah Akhir

DSTC
Perioperatif
Semester IX

Semester X
Panutan
Santun
Jujur
Empati