CASE PRESENTATION

ABDOMINAL TRAUMA

Preceptor:
Dr. Herry Setya Yudha Utama, Sp.B, M.HKes, FInaCS

Arranged By:
Raihan Alhazmi
1102013242

CLINICAL CLERKSHIP OF SURGERY DEPARTEMENT

FACULTY OF MEDICINE YARSI UNIVERSITY

ARJAWINANGUN DISTRIC GENERAL HOSPITAL

JULY 2017
 CASE PRESENTATION

I. IDENTITY
Date of hospital entry : July 3, 2017
Name : Mrs. N
Age : 15 y.o
Gender : Female
Address : Arjawinangun
Religion : Moslem
Marital status : Single

II. ANAMNESIS

Main Complaint

Patient complained about bruise in the back of her head, dizzy, nausea, throw up, and
abdominal pain.

History of Disease

Patients came to Arjawinangun hospital with complaints about bruise in the back of her
head, feeling dizzy, nausea, threw up, and abdominal pain. Four days ago, patient had
a traffic accident and lost her consciousness.

History of Past Disease

The patient said she had never experience the same symptoms before. The patient had
no history of surgery.

History of Family Disease

Mrs. Nsaid, there is no family member with the same condition with patient.
III. PHYSICAL EXAMINATION
a. Present Status
General condition : Mild pain
Awareness : Compos mentis
Blood pressure : 110/80 mmHg
Pulse : 80 x/minute, regular
Respiratory : 20 x/minute
Temperature : 36,6 oC

Head
Form : Normocephale, bruise in the back of the head
Hair : Black, no hair fall
Eye : Anemic conjungtiva (-/-), icteric sclera (-/-), light reflexes (+/+), isochore pupil
right = left
Ear : Normal form, cerumen (-), tympanic membrane intact
Nose : Normal form, septum deviation (-), epistaxis (-/-)
Mouth : Normal

Neck
Trachea is symmetrical, no deviation found, lymph nodes enlargement are not
present.

Thorax
Lungs Pulmonary
Inspection : chest is symmetrical
Palpation : fremitus vocal and tactile are symmetrical, crepitation (-), tenderness
(-), rebound tenderness (-)
Percussion : Sonor sound in both lung fields
Auscultation : Vesicular abd bronchial sound in the entire lung field, ronchi
(-/-), wheezing (-/-)
Cor

Inspection : Ictus Cordis not visible

Palpation : Cordis Ictus palpable

Percussion : cardiac boundaries within normal limits

Auscultation : BJ I-II Reg G (-) M (-)

Abdomen
Inspection : Flat, symmetrical, mass (-)
Palpation : Tenderness (-), rebound tenderness (-)
Percussion : Tympanity sound in four quadrants
Auscultation : Intestine sound (+)

Extremities
Upper
Muscle Tone : normal
Movement : active / active
Mass :-/-
Strenght :5/5
Oedema :-/-
Lower
Muscle tone : normal
Movement : active / active
Mass :-/-
Strenght :5/5
Oedema :-/-

Genitalia
No abnormalities
 b. Localized Status
Regio : Colli region
Inspection : Mass appears on the neck, same color as the surrounding skin, and
there are no signs of inflammation
Palpation : Palpable masses with flat surfaces

c. Laboratory Examination
Routine Haematology
USG
Thyroid Function Test

IV. DIAGNOSIS

V. DIFFERENTIAL DIAGNOSIS

VI. TREATMENT

VII. PROGNOSIS
Ad vitam :
Ad sanationam :
Ad fungsionam :
 LITERATURE REVIEW

1. Definition