Download - ess ES 9 jan 2014
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EMERGENCY SURGICAL SERVICES
The Attending Doctors :
1. Ely Sakti Chief
2. Dian Arie Vice Chief
3. Ubaidillah II
4. M. Reza Febrian II
5. Alvin B II
6.
Jonata P III
7. Rahwanda S III
8. Diah M III
9. Fadil P IV
10. Hengky P IV
11. Agus J IV
12. A H Kuncoro V
13. Tunjung R V
14. Donny Sandra V
15. Andri Tio V
16. Luthfi VI
17. Irfan VI
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Thursday, January 9th 2014
TRAUMA CASES ( 5 )
1. Mr. Warso / ♂ / 60 years old
D/ Electric burn injury (T22)
2. Boy Decky / ♂ / 7 years old
D/ Closed mild head injury of GCS 14 (S06.0) + EDH of left temporal region (S06.4) +
cerebral edema (S06.1)
3. Dai Robi / ♂ / 17 years old
D/ Closed mild head injury of GCS 15 (S06.0) + lacerataed wound on right auricle 4. (S10.3)
4. Mr. A. Nekson / ♂ / 31 years old
D/ Ruptur ulnar artery and nerve (S64.0) + ruptur of the flexor tendon group (S66.1) +
fracture distal of left ulnar extra articuler (S52.6)
5. Dodi A / ♂ / 18 years old
D/ Closed moderate head injury of GCS 13 (S06.0) + ICH of left frontotemporal region
(S06.3) + cerebral edema (S06.1)
NON TRAUMA CASES ( 3 )
1. Mrs. Wella / ♀ / 33 years old
D/ Acute appendicitis (K35.0)
2. Mr. Khuzairin / ♂ / 57 years old
D/ Perforation of gaster (K.65) + susp malignancy of the liver (K76.8)
3. Mr. Yan R / ♂ / 50 years old
Right pleural efusion (J91)
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TRAUMA CASES
1. Mr. Warso / ♂ / 60 years old
Admitted on Thursday, January 9th 2014 at 01.20 PM
Anamnesis
Electric burn injury
While he was working at the roof, his shoulder got shocked by electric power.
(about 3 hours before admission)
Referred from Dr. Rivai Abdullah, Palembang.
PRIMARY SURVEY
A. Good
B. RR : 22 x/m
C. BP : 150/90 mmHg
PR : 78 x/m
SECONDARY SURVEY
There are burn injury :
- Face : 4 % grade IIA
- shoulder : 0,5 % grade IIB
- Right leg : 7 % grade IIA
0,5% grade IIB
Total : 11% grade IIA and
1 % grade IIB
Dark urine ( + )
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ECG:
Sinus rhythm
LABORATORY FINDING:
Hb : 14,1 gr/dl (14 – 18 g/dl)
Ht : 41 vol% (40 – 48 vol%)Leucosit: 22.800 /mm3 (5000- 10.000/mm 3)
BSS : 154 mg/dL
CK-NAC : 9602 U/L (39-308 U/L)
CK-MB : 290 U/L (7-25 U/L)
Urinalysis : Eritrosit 10-15 /HPF (0-1/HPF)
DIAGNOSIS
Electric burn injury (T22)
THERAPY
- IVFD RL gtt XX/m (1800 cc / 24 hour)
- NGT + Urethral catheter
-Ceftriaxon 1x2 g IV
- Ketorolac 3 x 30 mg IV
-ATS 1500 IU IM
-Serial ECG
-Debridement
2. Boy Decky / ♂ / 7 years old
Admitted on Thursday, January 9th 2014, at 02.49 PM
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ANAMNESIS
Pain on his head after having traffic accident
He was hit by a motorcycle while she was crossing the street, his head hit the hard thing.
(About 2 days before admission)
Referred from Charitas Hospital, Palembang.
PRIMARY SURVEY
A. Good
B. RR : 24 x/min
C. PR : 104 x/min
D. GCS : E3M6V5 = 14, pupils were isochors, light reflexes were positive on both eyes.
SECONDARY SURVEY
On the Left Temporal region
I : Hematoma ( + )
RADIOLOGICAL FINDINGS
Head CT-Scan : EDH of left temporal region + cerebral edema
LABORATORY FINDINGS
Hb : 10,9 gr/dl (14 – 18 gr/dl)
Ht : 32 % (40 – 48 %)
DIAGNOSIS
Closed mild head injury of GCS 14 (S06.0) + EDH of left temporal region ((S06.4)) +
cerebral edema (S06.1)
THERAPY
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O2 mask 8 L/m
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- Head up 30°
- IVFD NaCl 0,9% gtt X/m (fluid demand 1500cc/day)
- Tramadol 3 x 15 mg IV
- Craniotomy emergency
IO :
- In the epidural space, we found blood and blood clot about 30 cc
- We evacuated blood and blod clot
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We inserted one drain subgaleal
The patient was treated in the ER
3. Dai Robi / ♂ / 17 years old
Admitted on Thursday, January 9th 2014, at 06.29 PM
ANAMNESIS
Pain on his head after having traffic accident
His motorcycle was hit by another motorcycle from front side. He fall and his head hit the
hard thing.
(About 4 hours before admission)
Referred from Bari Hospital, Palembang.
PRIMARY SURVEY
A. Good
B. RR : 20 x/min
C. BP : 110 / 70 mmHg
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- Tramadol 3 x 30 mg IV
- ATS 1500 IU IM
- Wound repair
4. Mr. A. Nekson / ♂ / 31 years old
Admitted on Thursday, January 9th 2014, at 08.11 PM
ANAMNESIS
Slashed wound.
He got slashed by someone using machete on his left hand.
(About 2 hours before admission)
Referred from Khodijah Hospital, Palembang.
PRIMARY SURVEY
A. Good
B. RR : 20 x/min
C. BP : 130 / 80 mmHg
PR : 96 x/min
SECONDARY SURVEY
On the Left Hand Region
I : Wound about 7x2 cm, reguler edge, muscle based
P : Allen test ulnar artery (+)
Hiposensation of hypothenar area
ROM were limited
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O2 saturation digiti :
I : 99 %
II : 98 %
III : 99 %
IV : 99 %
V : 99 %
RADIOLOGICAL FINDINGS
Left Hand X-Ray AP
Fracture distal ulnar extra articuler
LABORATORY FINDINGS
Hb : 11,3 gr/dl (14 – 18 gr/dl)
Ht : 33 % (40 – 48 %)
DIAGNOSIS
Ruptur ulnar artery and nerve (S64.0) + ruptur of the flexor tendon group (S66.1) + fracture
distal of left ulnar extra articuler (S52.6)
THERAPY
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IVFD RL gtt XX/m (fluid demand 2100cc/day)
- Ceftriaxone 1 x 2 g IV
- Ketorolac 2 x 30 mg IV
- ATS 1500 IU IM
- Repair wound
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Plan to perform ORIF
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IO :
Post operatively patient was treated in the ward
5. Dodi A / ♂ / 18 years old
Admitted on Friday, January 10th 2014, at 01.55 AM
ALLOANAMNESIS
Decreasing of conciousness after having traffic accident
His motorcycle got slipped, his fell and his head hit the hard thing.
(About 4 days before admission)
Referred from Dr. M. Yunus Hospital, Bengkulu.
PRIMARY SURVEY
A. Good
B. RR : 20 x/min
C. PR : 84 x/min
D. GCS : E3M6V4 = 13, pupils were isochors, light reflexes were positive on both eyes.
SECONDARY SURVEY
On the Left Frontal region
I : Hematoma ( + )
RADIOLOGICAL FINDINGS
Head CT-Scan
ICH of left frontotemporal region + cerebral edema
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DIAGNOSIS
Closed moderate head injury of GCS 13 (S06.0) + ICH of left frontotemporal region (S06.2)
+ cerebral edema (S06.1)
THERAPY
- O2 mask 8 L/m
- Head up 30°
- IVFD NaCl 0,9% gtt XX/m (fluid demand 1500cc/day)
- Tramadol 3 x 50 mg IV
The patient was treated in the ER.
NON TRAUMA CASES
1. Mrs. Wella / ♀ / 33 years olds
Admitted on Thursday, January 9th 2014 at 10.50 AM
ANAMNESIS
Pain on right lower abdomen.
About 1 day before admission, she complained epigastric pain that move and stayed at right
lower abdomen. Nausea ( + ), decreasing of appetite ( + ), fever ( - ).
Referred from Bhayangkara Hospital, Palembang.
VITAL SIGNS
Sense = conscious
BP = 120/80 mmHg
PR = 88 x/m
RR = 20 x/m
T = 36.8 ºC
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- We perform appendectomy the tissue sent to PA
Post operative diagnosis : Acute appendicitis (K35.0)
The patient was treated in the ER
2. Mr. Khuzairin / ♂ / 57 years olds
Admitted on Thursday, January 9th 2014 at 02.18 PM
ANAMNESIS
Pain on whole abdomen.
About 2 days before admission, he complained of pain on whole abdomen.
About 2 week before admission he complained of pain from epigastrium that move and
stayed at flank, nausea (+), vomite (-),
History of consumption reumatic medicine (+) since 1 month ago for the 2 weeks.
History right herniotomy 2010
Referred from Bhayangkara Hospital, Palembang.
VITAL SIGNS
Sense = conscious
BP = 140/90 mmhg
PR = 100 x/m
RR = 24 x/m
T = 36.8 ºC
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PHYSICAL EXAMINATION :
On the Abdominal Region
I : distended
P : defans muscular (+)
P : Tympani
A : Bowel sound (+) decrease
Right Inguinal region :
I : Scar op (+), Bulge that can reduce into abdominal cavity
NGT : greenish fluid
DRE : AST was good, mass (-),
ample wasn’t collapse
HS : Blood (-), feces (+)
RADIOLOGICAL FINDINGS
3 Position Abdominal Plain X-Ray
Bowel distention (-)
Herring bone (-)
Air fluid level (-)
Free air (+)
LABORATORY FINDING
Hb : 12,9 g/dl (14 – 18 g/dl )
Ht : 38 % (40 – 48 %)
Leucosite : 21.500 /mm3 (5 – 10.103/mm 3)
Trombosit : 153.000 (150.000-400.000)
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Na : 131 mEq / dl (135-145)
K : 4,8 mEq / dl (3.5-5.0)
AGD
pH : 7,37 (7,35 – 7,45)
pCO2 : 29.9 mmHg (35 – 45 mmHg)
pO2 : 110.1 mmHg (83 – 108 mmHg)
HCO3 : 17.7 mmol/L (21 – 28 mmol/L)
BEecf : - 7.7 mmol/L (-2 sd +3 mmol/L)
SaO2 : 98,1 %
PaO2/FiO2 : 183,6 mmHg
IO :
- In the abdominal cavity we found gastric content and fibrin about 500 cc that came out from
gaster perforation at prepiloric part with Ø 1cm
- We excise the edge of perforation, and sutured with PGA 3.0 R interuptedly PA
- On further exploration, we found surface of hepar not smooth and increasing size of lien
hepar biopsi PA
- We cleansed the abdominal cavity using warm normal saline
- We inserted one drain intraperitoneal
POST OPERATIVE DIAGNOSIS : Perforation of gaster (K.65) + susp malignancy of the
liver (K76.8)
The patient was treated in the P1
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3. Mr. Yan R / ♂ / 50 years olds
Admitted on Thursday, January 9th 2014 at 10.23 PM
ANAMNESIS
Shortness of breathing.
About 4 days before admission, he complained of shortness of breathing more severe.
About 3 months before admission, he complained of shortness of breathing. He got TB
medication for 3 months.
Referred from YK Madira Hospital, Palembang.
VITAL SIGNS
Sense = conscious
BP = 130/70 mmhg
PR = 94x/m
RR = 40 x/m
T = 36.9 ºC
PHYSICAL EXAMINATION :
On the Thoracic Region
I : simetric
P : sonor on left hemithorax, dullness on right hemithorax
A : vesicular ( + ) on left hemithorax, vesicular decreased on right hemithorax
RADIOLOGICAL FINDINGS
Chest X-Ray
Radioopaque of right hemithorax (+)
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RADIOLOGICAL FINDINGS
Chest CT Scan (RS Siloam)
Mass of right hemithorax (+)
DD/ Bronchogenic Ca / large cell Ca
DIAGNOSIS
Right pleural efusion (J91)
THERAPY
-
IVFD RL gtt XX/m (fluid demand 1800cc/day)
- Ceftriaxone 2 x 1 g IV
- Right chest tube initial : 700 cc serosanguinus
undulation : ( + )
air bubble : ( - )
exp bubble : ( - )
- Cultur of the effusion
RADIOLOGICAL FINDINGS
Chest X-Ray Control