Thursday, October 6th,2016

SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO GENERAL HOSPITAL
MAKASSAR

Thursday, October 6th

2016
Ambulation
:
1 Patient
Hospitalized

6 Patients

Observation

- Patient

Operated

- Patient

Death

- Patient

Total

7 Patients

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO GENERAL HOSPITAL
MAKASSAR

No. 1
Nam
: Mr. F
Sex
e
28 Years
No.
Age
:
Chief complaint
: Headache
old
Reg

: Male
: 774570

History taking

: Suffered since 4 hours before admitted to hospital due to

fell down from the stairs. There were no history loss of
consciousness, nausea and vomiting. Prior medical care
at Pangkep Hospital

Mechanism of
injury

: He was repair the plafond suddenly he slipped and fell

down about 2 meters with head bumped to the ground

Injury sustain

: Head

Symptom & sign : headache

Examination

: Physical examination, Head CT-Scan, laboratory

examination

PHYSICAL EXAMINATION
Primary Survey
A: Clear; Cervical Spine Control
B: RR : 18 x/minutes, spontaneous, symmetric,
thoraco abdominal type
C: HR : 82 x/minute, regular, adequate
D: GCS 15 ( E4M6V5 ), pupil equal 2,5/2,5 mm ,
LR +/+
E: T (ax) : 36,6oC

Secondary Survey
Right Frontal Region :
I : Seen excoriated wound, stitched wound
size 3 cm, no hematoma, no swelling, no
active bleeding
P : Tenderness (+) Crepitation (-)
Right Temporal Region :
I : Seen excoriated wound, lacerated
wound size 6x0,2cm, no hematoma, no
swelling, no active bleeding
P : Tenderness (+) Crepitation (-)
Right Parietal Region :
I : Seen stitched wound size 5 cm, no
hematoma, no swelling, no active bleeding
P : Tenderness (+) Crepitation (-)

HEAD CT-SCAN

Laboratory Result
WBC

15,46 x 103 / L

RBC

3,65 x 106 / L

HGB

11,0 g/dL

HCT

33 %

PLT

300 x103/ L

Blood Sugar :

170 mg/dl

Ureum

25 mg/dl

Creatinin

0,7 mg/dl

GOT / GPT

18 / 14 /L

WORKING
DIAGNOSE

: Traumatic Brain Injury GCS 15

MANAGEMENT

: O2

( E4M6V5)
Brain swelling

IVFD
Medicaments
Report to senior neurosurgeon
advice : conservative

No. 2
Nam
: Ms. S
Sex
: Female
e
16 years No.
Age :
: 774615
old
Reg
Chief complaint : Pain at right lower abdomen
History taking

: This condition had been suffered since 4 days before

admitted to ER. At the beginning she fell pain at the
umbilical and referred to right lower abdomen. There
were fever, anorexia, nausea, vomit, pain at the right
lower abdominal when she cough. Prior medical care
at Pelamonia Hospital

Micturation

: Normally

Defecation

: Normally

General Status
Moderate illness / well nourish / conscious

Vital Sign
BP
: 110/70 mmHg
PR
: 90 x/mnt, strong, reguler,
RR
: 20 x/mnt, symmetric L=R,
thoracoabdominal
type.
T(Ax) : 37,7 C

Abdominal

Local Status

I : flat, follow breath motion, skin color same with its vicinity,
bowel contour (-), bowel motion (-)
P : tenderness (+) at Mc Burney point, Rovsing sign (+),
Blumberg sign (+), muscular defans (-)
P : tapping pain (+), tympani
A : peristaltic (+) sound normal

Digital Rectal Examination

Sphincter tone was tight
Mucous was smooth
Ampulla filled with feces
There was pain at palpation at 10-11 oclock
Handscoen blood (-), feces (+), slime (-)

Laboratory Result
WBC

: 11.2 x 103 / l

RBC

3.94 x 106 / L

HGB

12.7 g/dL

HCT

38 %

PLT

299 x 103/ L

Blood
Sugar

114 mg/dl

Ureum

32 mg/dl

Creatinine : 0.6 mg/dl

GOT/GPT

: 38/36 u/l

PT/APTT : 12.0/27.2

Plano
test

: negative

ALVARADO
SHIFTING
SCORE

PAIN

ANOREKSIA
NAUSEA &
VOMIT

1
1

PAIN AT RIGHT
FOSSA ILIAKA

TAPPING PAIN
FEVER >37,2C
LEUCOCYTOSIS
10X10/L

1
1
2

NEUTROFIL
75%
TOTAL

0
9

Alvarado

Score

M : Mual-muntah

A : Anoreksia
N : Nyeri berpindah
T : Nyeri fossa iliaca
kanan

1
1
2

R : Nyeri lepas

E : Peningkatan suhu >

37,20C

L : Leukositosis >
10.000/L

S : Jumlah neutrophil >

75%

TOTAL

Alvarado Score
5-6 :
kemungkinan
kecil
7-8 :
kemungkinan
besar
> 9 : sangat
mungkin

USG ABDOMEN

WORKING
DIAGNOSIS

: Appendicitis acute

MANAGEMENT

: IVFD

Medicaments
Report to senior digestive
surgeon
advice : immediate
appendectomy

No. 3
Nam
: Ch. I
e

Sex

: Female

No.
Age
: 5 Years: Wound
old at the head
: 774592
Chief complaint
Reg
History taking

: The condition had been apparent since 15 minute

before admitted to the hospital due to accident. There
were no history of unconsciousness, nausea, vomiting.

Mechanism of
injury

: she was playing around the hospital when suddenly she

slipped and fell down with right head bumped to the floor

Injury sustain

: Head

Symptom & sign : Pain and wound

Examination

: Physical examination

PHYSICAL EXAMINATION
Primary Survey
A: Clear
B: RR : 24 x/minutes, spontaneous, symmetric,
thoraco abdominal type
C: HR : 90 x/minute, regular, adequate
D: GCS 15 ( E4M6V5 ), pupil equal 2,5/2,5 mm ,
LR +/+
E: T (ax) : 36,8oC

Secondary Survey
Right Frontal Region :
I : Seen lacerated wound size 4x2
cm, swelling, no active bleeding
P : Tenderness (+) Crepitation (-)

WORKING
DIAGNOSE

MANAGEMENT

: Traumatic Brain Injury GCS 15

( E4M6V5 )
Lacerated wound at right
frontal region
: Wound care and primary suture
Medicaments
Patient discharge

No. 3
Nam
: Mr. S
Sex
e
88 Years
No.
Age
:
Chief complaint
: Headache
old
Reg

: Male
: 774594

History taking

: Suffered since 11 hours before admitted to hospital due

to fell down from the stairs. There were no history loss of
consciousness, nausea and vomiting. Prior medical care
at Syekh Yusuf, Gowa Hospital

Mechanism of
injury

: He was walking on the stairs suddenly he slipped and

fell down with head bumped to the floor

Injury sustain

: Head

Symptom & sign : Headache

Examination

: Physical examination, Head CT-Scan, Laboratory

examination

PHYSICAL EXAMINATION
Primary Survey
A: Clear; Cervical Spine Control
B: RR : 19 x/minutes, spontaneous, symmetric,
thoraco abdominal type
C: HR : 76x/minute, regular, adequate
D: GCS 15 ( E4M6V5 ), pupil equal 2,5/2,5 mm ,
LR +/+
E: T (ax) : 36,9oC

Secondary Survey
Right Periorbital Region :
I : Seen hematoma, no swelling, no active
bleeding
P : Tenderness (+) Crepitation (-)
Nose Region :
I : Seen no wound, no hematoma, no
swelling, active bleeding
P : Tenderness (-) Crepitation (-)
Right Auricular Region :
I : Seen stitched wound size 6 cm, no
hematoma, no swelling, no active bleeding
P : Tenderness (+) Crepitation (-)

HEAD CT-SCAN

Laboratory Result
WBC

: 24.2 x 103 / L

RBC

4.49 x 106 / L

HGB

13.8 g/dL

HCT

41 %

PLT

333 x 103/ L

Blood
Sugar

155 mg/dl

Ureum

20 mg/dl

Creatinin

0,84 mg/dl

SGOT /
SGPT

47 / 28 /L

WORKING
DIAGNOSE

: Traumatic Brain Injury GCS 15

MANAGEMENT

: O2

( E4M6V5)
Multiplehematosinus

IVFD
Medicaments
Report to senior neurosurgeon
advice : conservative

No. 4
Nam
: Mr. F
Sex
e
38 Years
No.
Age
:
Chief complaint
: Headache
old
Reg

: Male
: 774569

History taking

: Suffered since 10 days before admitted to hospital.

There was history loss of consciousness, no history
nausea and vomiting. Prior medical care at Bulukumba
Hospital

Mechanism of
injury

: while working in the forest, suddenly fall of the logs on

the patient's head

Injury sustain

: Head

Symptom & sign : headache

Examination

: Physical examination, Head CT-Scan, Laboratory

examination

PHYSICAL EXAMINATION
Primary Survey
A: Clear; Cervical Spine Control
B: RR : 20 x/minutes, spontaneous, symmetric,
thoraco abdominal type
C: HR : 78 x/minute, regular, adequate
D: GCS 15 ( E4M6V5 ), pupil equal 2,5/2,5 mm ,
LR +/+
E: T (ax) : 36,8oC

Secondary Survey
Right Parietal Region :
I : Seen stitched wound size 7 cm, no
hematoma, no swelling, no active
bleeding
P : Tenderness (+) Crepitation (-)

HEAD CT-SCAN

Laboratory Result
WBC

8,55 x 103 / L

RBC

4,86 x 106 / L

HGB

14,5 g/dL

HCT

42 %

PLT

309 x 103/ L

WORKING
DIAGNOSE

: Traumatic Brain Injury GCS 15

MANAGEMENT

: O2

( E4M6V5)
Brain swelling

IVFD
Medicaments
Report to senior neurosurgeon
advice : conservative