Patient identity

Name
: Mirza
Age
: 21 years old
Sex
: Male
Address
: Dsn Geulumpang
rayeuk,
Peusangan, Bireun
MR
: 1-09-85-61
Phone
: 085362698976
Driving liscence : (+)
Patient came at : 04.00 AM

Chief Complaint
Pain at the right upper abdomen after trauma
History of present illness
Patient was referred from Bireun district
hospital to Zainal Abidin emergency room
with a chief complaint pain at the right upper
abdominal after trauma since 12 hours ago.
Initially, he get a ride motorcycle. Suddenly,
he was strucked by another motorcycle from
opposite. He felt down to the street and his
stomach hit the asphalt. History of nausea
and vomited (-), history of loss of
consciousness (-).

Physical examination
Primary Survey
A : Clear
B : Spontaneous, 20 breaths/min.
C : BP : 110/70 mmHg, Pulse : 98
beats/min
D : GCS E4 M6 V5 : 15
E : L/S at the abdominal region :
I : distension (-), hematoma (+) at the right side
A : bowel sound (+)
P : pain (+) at the right side. Diffuse abdominal
tenderness (-).
P : thympani (+)

Digital rectal examination:

Tonus sphincter ani : tight
Recti mucous : smooth
Recti ampulla
: faeces
Pain
: (-)
Glove
: Stool (-), blood (-), faeces
(+)

Assessment :
Blunt abdominal injury with
haemodynamic stabil

Management
IVFD RL 20 gtt/minute
Ceftriaxone inj 1 gr
Ketorolac 30 mg
Urinary catheter blood (-)
Laboratory examination
Radiology examination

Laboratory results:
Hb : 12,1 gr/dL
White blood count : 15.700/ul
Hematocrit: 40 %
Thrombosit : 299.000/ul
CT : 7
BT : 2
Cr : 1 mg/dl
Ur : 23 mg/dl
Chlorida : 110 mmol/L
Kalium : 4,2 mmol/L
Natrium : 141 mmol/L

Radiology result
USG Abdomen
Free fluid at the abdominal cavity (-)
Hematome at the right upper pole
renal

Diagnose :
Blunt abdominal injury with
haemodynamic stabil
Consult to digestive surgery
division :
NOM