BAB 3

CASE REPORT

Preceptor : Dr. dr. Bambang Arianto, Sp.B, FINACS

A. PATIENT IDENTITY

Name : Mr. Arief Hidayat H.

Age : 21 Years Old

Address : Prampelan, Magetan

Job : Employee of Building Construction TATA

Last education : Senior High School

Register number : 796215

Time of Injury : 25 January 2017, 15.00

Coming to emergency department : 25 January 2017, 15.20

Hospitalized IC/D5 : 25 Januari 2017, 22.00

B. SUBJECTIVE

1. PRIMARY SURVEY

Airway : Corpus alenium (-), Maksilofacial trauma (-), Additional breath,

sounds (-), gaps (-)

Breathing : spontaneously, symmetric, RR: 24 x/minute

Circulatiom : HR : 94 x/minute

Blood pressure : 110/60 mmHg

CRT < 2 detik

SpO2 : 100 %

Disability : GCS : 456

Round pupil isokor 3mm/3mm, Light reflex +/+

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 Exposure :Excoriation on back sinistra and hematome on flank sinistra,

bleeding (-), bone exposed (-)

2. SECONDARY SURVEY

Main complaint :

Pain on upper left abdominal area

HISTORY OF PRESENT ILLNESS :

Patient come to the Emergency Department of Surabaya Haji Hospital with

complain of upper left abdominal pain. Upper left abdominal pain felt after

struck by fitter glass machine while working twenty minutes ago. When strucked

by, the patient face down and heavy equiment on the heads and backs of the

patients. There is a wound in the head, back and mark bruise above his left waist,

pain (+), wound in the head was stitching in the Emergency Room. Patient

conscious well and can telling detail chronology of injury. Headache (+), nausea

(-), vomiting (-), seizures (-), urinate and defecate normally.

HISTORY OF PAST ILLNESS:

History of such illness is denied, history of any operation in abdomen is denied,

allergy of food and/or medicine is denied.

SOCIAL HISTORY :

The patient is an employee at Building Construction TATA, work 6-8 daily

hours, patient have last on meal 3 hours ago

3. GENERAL STATE :

General state : Weak, Weight: + 60 kg

Tax : 37 oC

Head/Neck : Anemis (+) /Ikteric -/Cyanosis -/Dyspnea-

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Thoraks

I : Normochest, symmetric, retraction (-)

P : Movement of the chestwalls symmetric, crepitation (-), deviated trachea

(-), widened intercostals space (-)

P : sonor/ sonor

A : breath sounds vesicular +/+, Ronchi -/-, Wheezing -/-

COR

I : Ictus does not seem

P : Ictus no palpable, thrill (-)

P : heart border normal

A : S1S2 single, Gallop (-), Murmur (-)

Abdomen

I : Flat simetris, lesion on flank sinistra, hiperemi (+), hematome (+), swelling

(-), vulnus (-), bleeding (-), bone exposed (-)

A : bowel sounds (+) weak

P : Soepel, tenderness (-), H/L/R no palpable, pain

- + +

- - +

- - -

P : Meteorismus (-), timpani (+), dull on hypocondrium sinistra

Ekstremitas :

o Warm akral

+ +

+ +

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o Oedema
- -

- -

o Cyanosis

- -

- -

o CRT < 2 dtk

4. LOCALISE STATE

Regio Thoraks posterior :

Excoriation et regio thoraks posterior sinistra, bleeding (-), pain (+), bone

exposed (-)

hematome at regio flank sinistra (+), pain (+), vulnus (-)

5. DIAGNOSIS

Suspect blunt abdominal trauma + Vulnus excoriatum et regio thoraks

posterior + COR

6. PLANNING DIAGNOSIS: -

- R Cervical Ap/Lat

- R Thoraks Ap/Lat

- R L/S Ap/Lat

- USG FAST Abdomen

- CT scan skull axial non contras

- DL serial/2jam

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 7. PLANNING THERAPY

- Consult to general surgeon

- 2 line infusion RL

- Inj Ceftriaxone 2 x 1 gram iv

- Inj. Antrain 3 x 500 mg iv

- Inj Ranitidin 2 x 50 mg i

- Inj. Tetagam

- Inj. Piracetam 3 x 3 g

- Set abdominal circumferential

8. PLANNING MONITORING

- General state

- Patient complaint

- Vital sign observation/15 minutes

- Abdominal circumferential observation/2 hours

The picture of patient:

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 USG Abdomen :

hipoecoic lesion border not spesific up to middle pole, look like much fluid

(internal bleeding) on morison pouch, perilienal, pervesica and subdiaphragma

with conclusion internal bleeding et causa splenic injury

R Cervical Ap/Lat : normal

R Thoraks Ap/Lat : normal

R L/S Ap/Lat : normal

CT SCAN skull axial non contrass : like mild edema cerebri, intracranial bleeing

(-), midline shift (-), fraktur (-)

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