case report 8 desember 2014 edited

Emergency Case Report2014, 8-9TH December

Resident on Duty : dr. Alma WijayaChief Co-Assistant : Bimo Harmaji

Team : Endah, Erina, Mira, Firdha, Dyah, Ady

Minor Surgery : -

Digestive Surgery : 1

Thorax Cardiovascular Surgery : -

Plastic Surgery : 1

Urology Surgery : -

Neurosurgery : 2

Pediatric Surgery : 1

Oncology Surgery : -

Orthopaedy : -

Total : 5

No Identity Admission to E.R. Diagnosis Treatment / Planning

1Indah Nuraini/

19 y.o/ 1.13.11.08

8th December 2014/ 05.00

p.m

Hypovolemic shock rapid response + Obs blunt abdominal trauma with susp spleenic rupture +

sup hepatic rupture Severe Head Injury GCS 8 dd secondary Brain Injury

+ closed fracture of the right femur midle third transverse displaced

IVFD resucitation 110/70 NOksigenationConsul digestif surgery Advice : Resusitation

Pro LE damage control surgery, Transfusion preparation

Preparing for USG if stable condition

-Consul NeurosurgeryAdvice : ResusitationCT brain contusion agree for damage control Co Orthopaedic :Apply skin tractionORIF elective


2An. Rahman/ 8

month old/ 1.13.11.22

8th December

2014/ 10.00 p.m

Obstructive Ileus high level due to ? Dd ileus

due to electrolit imbalance with hiperkalemia,

hiponatremia and anemia

IVFD moderate rehidrationDecompression

AntibioticH2 blocker

Co pediatric Surgery :General condition improvement

Join care with pediatric dept


3An Imron Rofiq

13 y.o/ 1.13.11.21

2014, 8TH December/ 10.30 p.m

Moderate head Injury GCS 13 E3M6V4 +

cerebral edema

Consul neurosurgery :Konserfative treatment

- IVFD NS maintenance- Antibiotic- Analgesic- H2 Blocker

- GCS observation


4Tn Horman 53 y.o/ 1.13.11.25

2014, 8TH December/ 11.30 p.m

Haemorhagic stroke With ICH 12cc ar thalamus +

IVH

Consul neurosurgery :-Pro Observation GCS and vital sign

-IVFD NS 30 tpm-AnalgeticAntiemetic

Antihipertensive agent


5Tn Tendix Vega

Ariyanto/ 21 y.o/ 1.13.11.27

2014, 9TH December/ 01.30 a.m

Fraktur of the right parasymphisis mandibula

Consul plasticsurgery :-IVFD RL Maintenance

AntibioticAnalgesicH2 blocker

Anti FibrinoliticPro Re Hecting

Pro Orif Platin ElectiveBeeding tamponade

Oral hygene

1. Ms. Indah Nuraini/ 19 y.o/ 1.13.11.08 5th December 2014/ 05.00 p.m

Chief Complain : Unconsious

History: 2,5 hours ago before admission, the patient had an accident . The patient was, riding a motorcycle at high speed and hit the truck. The patient lossing her balance and suddenly hit stopped the truck. The patient was throwm, with head, stomatch and right foot hit truck body. After the incident, patient was taken to ER Pelaihari by citizen around. Patient got 2 kolf PRC at ER Pelaihari.

Because the complain patient in Pelaihari Hospital, patient referred to Ulin General Hospital for further treatment.

Primary Survey

• ClearA

• Clear, RR= 22 bpm, symmetric respiratory movement, symmetric

VBSB

• BP : 70/50 mmHg• Pulse rate : 128 bpm, reguler,

weak lifted, CRT < 2 sec. C

• GCS E2V5M2, round and equal pupils diameter (3mm/3mm),

light reflexes (+/+), no paralysisD

A -

M IVFD 1L

P -

L 9-10 hour before admission

E On the road

Physical examination• Eyes : anemic conjunctiva, icteric sclera (-), • Nose : No epistaxis• Mouth : Wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck

• I : Symmetric respiratory movement, no retraction• P : Symmetric VF• P : Sonor at all lung fields• A : Symmetric VBS, no rhonchi, no wheezing

Chest

• I : Injury + at RUQ and LUQ• A : Bowel sound (+) • P : soeple, Liver/spleen/kidney not palpable, mass not palpable,

tenderness + DM + • P : Tymphani

Abdomen

• Cold acral localize at right femur , no pareseExtremities

Rectal Toucher• Anal sphingter : strong• ampulla was not collapse • Smooth mucous• Blood -

Clinical Picture – Local Status

Hematom at right frontal region


Excoriation wound at upper left region, upper right region DM +

L : edema + deformity +F : False movement +M : Limited

Laboratory

• Hb 6.9 g/dl• Leukosit 20900/ul• Eritrosit 320/ul• Hct 21,7%• Trombosit 235000/ul• RDW-CV 16.1%• SGOT/PT 640/235 U/I

• Hasil PT : 22.3 detik• Control normal PT : 11,4• Natrium : 140.3 mmol/l• Kalium : 3.8 mmol/l• Chlorida : 105.4 mmol/l

Working Diagnosis

Hypovolemic shock rapid response + Obs blunt abdominal trauma with susp spleenic rupture + susp hepatic rupture + Severe Head Injury GCS

8 dd secondary Brain Injury + closed fracture of the right femur midle third transverse displaced

Management

IVFD resucitation 110/80

Oksigenation

Vital sign Observation

Consul digestif surgery

Advice : Resusitation

Pro LE damage control surgery, Transfusion preparation

Preparing for USG if stable condition

-Consul Neurosurgery

Advice : Resusitation

CT brain contusion agree for damage control

Co Orthopaedic :

Apply skin traction

ORIF elective

2. An M. Rachmani/ 8 m.o/ 1.13.11.22 8th December 2014/ 10.00 p.m

• Chief Complain : unable to defecation• History:

Since 2 days before hospital admission patient been complained couldn’t defecation and flatus. The patient got vomit 3 days before hospital admisson. The vomit was food contained . The patient also got diarhea 6 days before admission, the componet secret and contain mucous. History of fever – history of passage abnormality before - The patient hasn’t history of late of meconium. The patient was first child. The weight was 2800 gr. Patient always control ANC regularly and got all of imunitation.

Because the complain patient in Pelaihari Hospital, patient referred to Ulin General Hospital for further treatment. Because his complain patient referred to Ulin General Hospital for further treatment.

Physical Examination• Conciousness : Compos Mentis• Vital sign :

• HR = 120bpm• RR = 38 bpm• T = 36,8ºC

Physical Examination

• Eyes : anemic conjunctiva - , icteric sclera (-), sunken eye +• Nose : No epistaxis• Mouth : Wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck


Chest

• I : look distended + • A : Bowel sound decreased, metalic sound + • P : soeple, Liver/spleen/kidney not palpable, mass not palpable,

tenderness (-), DM -• P : Tymphani

Abdomen

• Warm, no oedema, no pareseExtremities


Rectal toucher :

- Strong TSA - Colaps ampula- Mass (-)- Feces (-)- Mucous (-)- Blood (-)- Rectal tube insertion no fecal content

Abd AP

Laboratory

• Hb 8.8 g/dl• Leucocyte 10600 /µl• Hematocrit 27,9 vol%• Trombocyte 823000/ µl• SGOT/SGPT 44/13 U/l• Ur/cr 47/0.5 mg/dL• Na/K/Cl 125,1/6,1/91,6 mmol/l

Working Diagnosis

Obstructive Ileus high level due to ? Dd ileus due to electrolit imbalance with

hiperkalemia, hiponatremia and anemia

Management

• IVFD moderate rehidration• Decompression

• Antibiotic• H2 blocker

• Co pediatric Surgery :• General condition improvement

• Join care with pediatric dept

3. An Imron Rofiq/ 13 y.o/ 1.13.07.962014, 8TH December/06.30 p.m

Chief Complain: decrease of concious History : 8 hours before admission, his friend and the patient

drive motorcycle together, suddenly the patient lost control and balance, the patient drop up to the ground and his head hit the road. Then the patient was taken to the ER primary health care in Kapuas, the patient didn’t got primary survey adequately and then referred to Ulin General Hospital for further treatment.

Primary Survey

• Clear, Snoring (-), gurgling (-),A


VBSB

• Pulse rate : 108 bpm, reguler, strong lifted, CRT >2 sec.

C

• GCS E3V3M5, round and equal pupils diameter (3mm/3m), light

reflexes (+/+), no paralysisD

A -

M IVFD, Wound toillete

P -

L 8 hours before admission

E Road

Secondary survey

•Eye : Anemic conj. (-/-), icteric sclera (-/-), oedem (+) localize•Mouth : wet mucous•Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)

Head/Neck

• I : Symmetric respiratory movement, retraction (-)• P : Symmetric VF• P : Sonor in all lung field• A : Symmetric VBS, Rh (-/-), Wh (-/-)

Chest

• I : Wound (-), distension (-), hematoma (-)• A : Normal bowel sound• P : H/L/M not palpable, tenderness (-). • P : Tympanic in all quadrants

Abdomen

• Warm, edema (-), paralysis (-)• Wound (+)Extremities


Multiple excoriation +

Racoon eye –

Battle sign –

Ottorhagia –

Rinnorhagia -

Laboratory

Hb 12.2 g/dl Leucocyte 12200/µl Hematocrit 36.3 vol% Trombocyte 237000/ µl SGOT/SGPT 54/22U/l Ur/Cr 27/0.7 mg/dL Na/K/Cl 140,5/4,1/105,0

mmol/l

Working Diagnosis

Moderate head Injury GCS 13 E3M6V4 + cerebral edema

Management

• Consul neurosurgery :Konserfative treatment- IVFD NS maintenance

- Oksigenation- Antibiotic- Analgesic- H2 Blocker

- GCS observation

4. Tn Horman/ 53 y.o/ 1.13.11.25 8th December 2014/ 11.30 p.m

Chief Complain : Severe Headache

History: Since 2 days ago before admission, the patient got severe headache. The pain not lost with treatment (drug) . The patient also complained vomit and weakness left extremite. History of seizure -. The patient hipertension history.

Because the complain patient in Sampit Hospital, patient referred to Ulin General Hospital for further treatment.

Physical Examination• Conciousness : Compos Mentis• Vital sign :

• HR = 110 bpm• RR = 36,5 bpm• T = 36,8ºC• BP = 180/90 mmhg


• Eyes : anemic conjunctiva, icteric sclera (-), • Nose : No epistaxis• Mouth : Wet mucosa• Neck : Lymph nodes enlargement (-), JVP enhancement (-)

Head/Neck


Chest

• I : Inguinal lymph nodes enlargment (-)• A : Bowel sound (+) • P : soeple, Liver/spleen/kidney not palpable, mass not palpable,

tenderness (-), • P : Tymphani

Abdomen

• Warm, no oedema• 5 2• 5 2

Extremities

Clinical Pictures

Laboratorium• Hb 15,0 mg/dl• Hematokrit 41,0 vol%• Leukosit 9800 ul• Trombosit 213.000 ul• GDS 144 mg/dl• SGOT/SGPT 18/13 UI/L• Ureum/Kreatinin 28/1,9 mg/dl

Working Diagnosis

Haemorhagic stroke With ICH 12cc ar thalamus + IVH

Management

• Consul neurosurgery :• -Pro Observation GCS and vital sign

• -IVFD NS 30 tpm• -Analgetic• Antiemetic

• Antihipertensive agent

5. Tn Tendix Vega/ 21 y.o/ 1.13.11.27 9th December 2014/ 01.40 a.m

Chief Complain : lower jaw pain

History: Since 2 hours ago before admission, the patient when drive a motorcycle, suddenly he lost balance and control. The patient fall, his chin hit the road. The patient complained pain at his lower jaw. He can’t open his mouth and bleeding from his mouth. History of fainted – Bleeding from ear and nose -

Because the complain patient in RSUD Banjarbaru Hospital, patient referred to Ulin General Hospital for further treatment.

Primary Survey

• Clear, Snoring (-), gurgling (-),A


VBSB

• Pulse rate : 92 bpm, reguler, strong lifted, CRT >2 sec.

C

• GCS E4V5M6, round and equal pupils diameter (3mm/3m), light

reflexes (+/+), no paralysisD

A -

M Antibiotic, Analgesic,

Antifibrinolitic

P -

L 2 hours before admission

E Road

Secondary survey

•Eye : Anemic conj. (-/-), icteric sclera (-/-), racoon eye (-/-) •Mouth : wet mucous, step defect (+), mandibula : unstable, bleeding (+)•Neck : JVP enhancement (-/-), lymphatic nodes enlargement (-/-)

Head/Neck

• I : Symmetric respiratory movement, retraction (-)• P : Symmetric VF• P : Sonor in all lung field• A : Symmetric VBS, Rh (-/-), Wh (-/-)

Chest

• I : Wound (-), distension (-), hematoma (-)• A : Normal bowel sound• P : H/L/M not palpable, tenderness (-). • P : Tympanic in all quadrants

Abdomen

• Warm, edema (-), paralysis (-)• Wound (+)Extremities

Laboratory Hb 14,8 g/dl Leucocyte 16700/µl Hematocrit 41.9 vol% Trombocyte 186000/ µl Hasil PT 14,2 detik Hasil APTT 25,2 detik SGOT/SGPT 115/46 U/I

Open wound 6cm in length, irreguler edge base on bone

Working diagnosis

Fraktur of the right parasymphisis mandibula

Management

• Consul plastic surgery :• -IVFD RL Maintenance

• Antibiotic• Analgesic• H2 blocker

• Anti Fibrinolitic• Pro Re Hecting

• Pro Orif Platin Elective• Beeding tamponade

• Oral hygene

TERIMAKASIH

case report 8 desember 2014 edited

Documents

patient lossing

upper right region

diagnosistreatment planning3

diagnosistreatment planning2an

right foot

moderate head injury

pediatric surgery

pelaihari hospital