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EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Saturday, March 1st 2014
Ambulation : Patient
Hospitalized : patients
Observation : patient
Operated : patient
Death : patient
Total : patients
No.
Name : Mr. U Sex : Male
Age : 21 years No. Reg : 653015
Defecation : Normal
Micturated : Normal
Physical Examination
General Conditions:
Moderate illness / well nourish / conscious
Vital sign:
BP : 120/70 mmHg
PR : 76 x/mnt, regular, adequate.
RR : 21 x/mnt.
T(Ax) : 37 °C
PHYSICAL EXAMINATION
Abdomen
I : Seen convex, follow breath motion, no bowel contour, no bowel
motion, no tumor mass.
P : Tympani
Rectal Toucher
Ureum : 43 mg/dl
MANAGEMENT : IVFD
Apply NGT
Apply Foley Catheter urine
Medicaments
Report to Senior Digestive Surgeon
advice : Immediate Laparotomy
OPERATION PROCEDURE
• Patient laid supine under GA
• Disinfection and drapping procedure
• Performed midline deepen layer by layer, until
peritoneum
• Identify, seen dilatation on every part of the bowel
• Seen volvulus ileum and multiple band, 50cm on distal
part and 90 cm proximal part from the ileocaecal valve
• Seen ischemic part of the ileum, resection of the ileum is
performed
• Decompression of the of the dilatated ileum
• Perform end-to-end anostomosis
• Control the bleeding and rinse cavum abdomen
• Close wound layer by layer with 1 drain
• Done
POST OP DIAGNOSIS : •Intestinal obstruction e.c volvulus
•multiple band
•SIRS
PROGNOSIS : Good
History taking : This condition had been apparent since 1 year ago. The
lump would be bigger when he was standing and would
be smaller when he lied. The symptom aggravates when
before while his abdomen distended. The lump along
without pain and can not reduce again.
Micturation : Normally
Defecation : Normally
General Status
Moderate illness / well nourish / conscious
Vital Sign
BP : 100/80 mmHg
PR : 84x/mnt, strong, reguler,
RR : 18x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 36,8°C
Local Status
Abdominal
I : Flat, follow breath motion, skin color same with vicinity, bowel contour
(-), bowel motion (-)
A : Peristaltic (+) sound normal
P : Tenderness (-) ,Tumor mass (-)
P : Tympani
Local Status
Scrotal region region
I : Seen ovale lump from craniolateral to caudomedial until scrotum,skin
color reddish than vicinity
P : Palpable lump at right scrotum, soft consistency , tendernes(+),
palpable 2 testis normally
A : Peristaltic (-)
Digital Rectal Examination
Sphincter tone was tight
Mucous was smooth
Ampulla collaps
Handscoen: blood (-), feces (-), slime (-)
BNO X-Ray
Laboratory Result
WBC : 15,7x 103 / μL
HCT : 33%
PLT : 334x103/ μL
Ureum : 16 mg/dl
Creatinin : 0,3mg/dl
40/ 11 μ/L
GOT / GPT :
WORKING DIAGNOSIS : •Hernia Inguinalis Dextra Incarserated
•Hidrocele dextra
MANAGEMENT : • IVFD
• Medicaments
• Report to senior Pediatric surgeon
advice : Herniotomy and Hernioraphy
Operation Procedure
• Patient laid in supine position under GA
• Draping and disinfection procedure
• Tranversal incision10 cm under umbilicus, deepen until peritoneum
• Open peritoneum, seen yellowish fluid, like ascites, about 500cc,
dilate tranversum colon
• Identify intraperitoneal organ, seen herniation of ileum to anulus
inguinalis dextra. Liberate hernia sac that still viable
• Perform hidrokelektomi peringuinal, by making incision of 3 cm
above inguinal ligament, deepen until hernia sac
• Ligate hernia sac as proximal as possible
• Control bleeding, apply drain in douglas pouch
• Close operation wound layer by layer
• Operation is done
POST OP DIAGNOSIS : •Hernia Inguinalis Dextra Incarserated
•Hidrocele dextra ascites
PROGNOSIS : Fair
HCT : 38,3 %
CT / BT : 8‘00” /2’00”
Ureum : 25 mg/dl
MANAGEMENT : • O2
• Apply IVFD
• Medicaments
• Consult to senior Neurosurgeon
Advice: Proceed Craniectomy
No.
Name : Mr. I Sex : Female
Age : 40 years No. Reg : 653029
History taking : The complaint had been apparent for 1 week. Her
abdomen is distended gradually. There were no events of
vomiting and fever before.
Defecation : Normally
Micturation : Normally
Physical Examination
General Conditions:
Moderate illness/well nourished/composmentis
Vital sign:
BP : 110/80 mmHg
PR : 84x/mnt, regular, adequate.
RR : 20x/mnt.
T(Ax) : 36,9 °C
PHYSICAL EXAMINATION
Abdomen
I : Abdominal distended
P : Tympani
Abdominal X-Ray
Abdominal USG
Abdominal
CT Scan
Chest X-Ray
Laboratory Result
WBC : 12,4x 103 /μL
HGB : 11.1g/dL
HCT : 34%
CT / BT : 8’30”/3’30”
Ureum : 27 mg/dl
MANAGEMENT : • Medicament
• Proceed Wound Care
No.
Name : Mr. HT Sex : Female
Age : 15 years No. Reg : 653025
History taking : This condition has been apparent for 1 day before
admitted to the hospital due to head injury. History loss
of consciousness (+) nausea (+) vomiting (-).
Mechanism of : He was riding motorcycle in high speed, then he loose
injury his balance and fall down with his head and face facing
the ground.
E: T (ax) : 36,7 oC
Secondary Survey
Right zygoma region :
I : Seen excoriated wound size 2x1 cm, edema(+),
hematoma(+), active bleeding(-), deformity (-)
P : Tenderness (+), Crepitation (-)
Laboratory Result
WBC : 12,6 x 103 / μL
HCT : 37 %
CT / BT : 7 ‘00” / 3 ’ 00”
Ureum : 21 mg/dl
MANAGEMENT : • O2
• Medicaments
• Report to senior neurosurgeon
advice : Conservative
PROGNOSIS : Good
FOLLOW UP : Vital sign
No.
Name : Mr. H Sex : Male
Age : 19 years No. Reg : 653012
History taking : This condition has been apparent for 8 days before
admitted to the hospital due to head injury, he’s been
awake in the last 4 days, History loss of consciousness
(+) nausea (+) vomiting (-).
Mechanism of : He was riding motorcycle in high speed, then he loose
injury his balance and fall down with his head and face facing
the ground.
E: T (ax) : 37,1 oC
Secondary Survey
Right zygoma region :
I : Seen excoriated wound size 4x3 cm, edema(+), hematoma(+),
active bleeding(-), deformity (-)
P : Tenderness (+), Crepitation (-)
Laboratory Result
WBC : 15,5 x 103 / μL
HCT : 37 %
CT / BT : 78‘00” / 2 ’ 00”
Ureum : 28 mg/dl
MANAGEMENT : • O2
• Medicaments
• Report to senior neurosurgeon
advice : conservative
PROGNOSIS : Good
E: T (ax) : 37,5oC
Secondary Survey
HCT : 37 %
CT / BT : 8‘00” / 3’ 00”
Ureum : 17 mg/dl
MANAGEMENT :
O2
IVFD
Medicaments
Report to senior neurosurgeon
advice : immediately trepanation
No.
Name : Mr. I Sex : Male
Age : 45 years No. Reg : 651445
History taking : This condition has been apparent for 2 hours before
admitted to the hospital due to traffic accident. History
loss of consciousness (+) nausea (+) vomiting (-).
Mechanism of : He was riding motorcycle, then he loose his balance and
injury hit a tree, and fall down with his head and face, bumped
to the ground
E: T (ax) : 36,8 oC
Secondary Survey
Frontal region :
I : Seen lacerated wound size 4x2 cm (+),
hematoma(+), excoriation (-), active bleeding(-),
deformity (-)
P : Tenderness (+), Crepitation (-)
RBC : 1, 80 x 106 / μL
HCT : 16, 8 %
CT / BT : 7 ‘00” / 3 ’ 00”
Ureum : 46 mg/dl
Creatinin : 1, 1 mg/dl
: Good
FOLLOW UP : Vital sign
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