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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
Mechanism of : The patient was drunk with his friends and suddenly they
injury were fighting. He got stab by his friend
Primary Survey
A: Clear
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 (-)
CT / BT : 800 / 200
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
Primary Survey
A: Clear
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 %
CT / BT : 600 / 200
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
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
E: T (ax) : 36,2oC
Secondary Survey
Right Zygoma Maxila Region :
I : Seen edema (+), hematoma (+)
P : Tenderness (+), crepitating (+)
Mandibula Region :
I : deformities (+), hematoma (+)
P : Tenderness (+), crepitating (+)
HCT : 33,3 %
CT / BT : 600 / 300
Ureum : 30 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
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.
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 %
CT / BT : 700 / 300
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
Makalah III
(Nasional)
Makalah Akhir
DSTC
Perioperatif
Semester IX
Semester X
Panutan
Santun
Jujur
Empati