Djumadi, L, 

76 th, 01992123
Primary Survey:
A: talk clearly, snorring (-), gurgling (-) -> clear
B: RR 20 x/mnt, SpO2 100% on NRM 10 lpm, simetris (+), KG (-), (sonor/sonor), vesikuler (+/+) ->
clear
C: warm extremity (+), BP 115/80 mmHg, HR 100 x/mnt, CRT <2 dtk --> clear
D: GCS E4V5M6

Initial assessment: No Potential Life Threatening

Secondary Survey:
A: tidak ada
M: tidak ada
P: tidak ada
L: last meal 09.30
E: traffic accident

Chief complain :
Pain on his face, right hand, and left lower leg

History of illness:
6.5 hours before admission (11.00) while the patient was riding a motorcycle, he suddenly crushed
by another motorcycle from opposite direction. He fell to ground. He didn’t remember the accident,
there was history of fainting (+), no severe headache, no vomitus. He complained pain on his face,
pain on his right hand and left lower leg. The patient then admitted to PDHI hospital and underwent
head ct scan and radiograph examination. He then referred to Sardjito hospital for further
examination

Past Illness:
HT (-), DM (-), jantung (-), alergi (-)

Pemeriksaan Fisik
General condition moderate, GCS, E4V5M6
BP: 115/80 mmHg
HR: 100 x/mnt
RR: 20 x/mnt
SpO2 100% on NRM 10 lpm
S: 37°C

Head:
Pupil isokor 3 mm/3 mm, CA (-/-), SI (-/-), RC (+/+), RK (+/+)

Upper face
I : simetris, VE (+), VL (+) frontal region with size 2cm (sutured), hematoma (-), swelling (-), bleeding
aktif (-)
P: sensoris dbn, NT (+), krepitasi (-)
Middle face
I : asimetry, racoon eye (-/-), hematoma (+)bilateral periorbital regions, telekantus (-), diplopia (-),
eye movement dbn, edema (-), rhinorrhea (-), bloody otorrhea (-), battle sign (-), deviasi septum nasi
(-), step off (-) , VE (-), VL (-)
P : sensoris dbn, floating maxilla (+), NT (+), krepitasi (+)

Lower face
I : asimetry, avulsi dental (-) VE (-), VL(+) labium superior, edema (-), deformitas (-) maloklusi (-),
hematoma (+)
P : sensoris dbn, NT (-), gliding mandibula (-), krepitasi (-)

Leher:
Jejas (-), JVP tidak meningkat, NT (-)

Thorax:
I: Jejas (-), simetris (+), ketinggalan gerak (-/-)
P: VF ka=ki
P: sonor/sonor
A: Vesikuler (+ /+), wheezing (-/-), ronkhi (-/-)

Abdomen:
I: Distensi (-), VE (-)
A: BU (+) normal
P: Supel, defans (-), NT (-)
P: timpani (+)  

Pelvis:
I: Jejas (-)
P: NT (-), Krepitasi (-)

Ekstremitas:
Akral hangat (+), CRT <2 detik

Localized status of the right hand

L : Swelling (-), hematome (-), VE (-), VL (+) on thumb with 2cm in size (sutured), aktive bleeding (-),
deformity (+) metacarpal V, angulation (+), shortening (+)
F : NT (+), krepitasi (+), NVD (-)
M : ROM terbatas karena nyeri

Status lokalis cruris sinistra

L : Swelling (-), hematome (-), VE (-), VL (+) cruris sinistra panjang 10 cm, terhecting, aktif bleeding (-),
deformity (+)
F : NT (+), krepitasi (+), NVD (-)
M : ROM terbatas karena nyeri

Ass:
- TASDH of the left FTP region
- Fracture Le fort II
- NOE frature type I
- left ZMC fracture
- VL regio frontal terhecting
- VL labium superior
- Close fracture metacarpal V manus dextra
- suspek Open fracture head metacarpal digiti I manus dextra
- Open fracture tibia fibula 1/3 proksimal sinistra

Plan
Neurosurgery:
- rawat HCU
- head up 30°
- Mannitolisasi

Orthopaedi:
- debridement + explorasi + resuturing VL digiti I manus dextra
- pro ORIF elektif setelah program mannitolisasi selesai

Plastic surgery: (usul)

- head up 30°
- primary suture VL labium oris superior dengan Vicryl 4.0
- resuturing VL frontal dengan Vicryl 4.0 dan Nylon 5.0  refused procedure
- rawat luka tertutup dengan salep chloramphenicol + tulle untuk luka di frontal
- oral hygiene dengan betadine kumur
- pro reconstruction of facial bones elektif
Muhammad Daffa, L, 15th, 1992136
Primary Survey:
A: bicara jelas (+), snoring (-), gargling (-) --> Clear
B: RR 24 x/menit, SpO2 99% on NK 3lpm, simetris (+), KG (-), hipersonor/sonor, vesikuler
(menurun/+) --> clear
C: Akral hangat (+), TD 132/65 mmHg, HR 91 x/menit, CRT <2" --> clear
D: E4V5M6, pupil isokor 3 mm/3 mm, lateralisasi (-)
E: post disabet celurit di punggung kanan

Initial assessment: No potential life threatening

Secondary Survey:
A : Tidak ada
M : Tidak ada
P : Tidak ada
L : makan nasi jam 18.30
E : post disabet celurit di punggung kanan

Chief complain: pain on his right back and shortness of breath

History of illness:
6 hours before admission while the patient was riding a motorcycle, his back was stabbed with
“Celurit” by another rider. The patient didn’t fall from his motorcycle. He felt pain on his right back,
and he felt dyspnoe. He then admitted to Palang Merah hospital and underwent chest X-ray and was
diagnosed as right pneumothorax. He also underwent primary suture of his open wound. He then
referred to Sardjito hospital for further management

RPD:
Alergi (-), DM (-), HT (-)
Stroke (-), Peny. Jantung (-), Peny. Ginjal (-),Asma (-)

Physical examination :
KU sedang, CM
TD: 132/65 mmHg
N: 91x/mnt
RR: 24 x/mnt
S: 37°C
SpO2 99% on NK 3 lpm

Kepala:
Pupil isokor 3 mm/3 mm, CA (-/-), SI (-/-), RC (+/+), RK (+/+)

Leher:
Jejas (-), JVP dbn, VE (-), VL (-)

Thorax:
I: Simetris (+), deformitas (-), VL (+) on his right back region with 5cm in size (sutured)
P: VF increased > kiri
P: hipersonor/sonor
A: Vesikuler (decreased/+), wheezing (-/-), ronkhi (-/-)
Abdomen:
I: Distensi (-) jejas (-)
A: BU (+) normal
P: Timpani (+)
P: Supel (+), NT (-)

Pelvis: pelvis stabil (-), NT (-)

Ekstremitas:
Akral hangat, CRT <2 detik, edema (-), lateralisasi (-)

Assessment (usul):
- Right pneumothorax
- VL regio punggung kanan terhecting

Plan (usul):
- Cek lab lengkap
- inj. Ceftriaxone 1gr/12 jam
- inj. Ketorolac 30mg/8jam
- inj. Ranitidin 50mg/12 jam
- inj. Tetagam 250IU IM
- pro insersi chest tube dextra
- ro thorax evaluasi post insersi chest tube
Fathul Qarib, L, 19 th, 1992134
Primary Survey:
A: talk clearly (+), snoring (-), gargling (-) --> Clear
B: RR 20 x/menit, SpO2 99% on room air, simetris (+), KG (-), sonor (+/+), vesikuler (+/+) --> clear
C: Akral hangat (+), BP 113/68 mmHg, HR 90x/menit, CRT <2" --> clear
D: E4V5M6, pupil isokor 3 mm/3 mm, lateralisasi (-)
E: post KLL

Initial assessment: potential life threatening

Secondary Survey:
A : Tidak ada
M : Tidak ada
P : Tidak ada
L : makan nasi jam 01.00
E : post KLL

Chief complain: abdominal pain

History of illness:
30 minutes before admission the patient was found fell to the water gutter near the RSH. The
patient didn’t remember the accident, no severe headace, no vomitus, no chest pain. He complained
pain on his abdomen. He then admitted to Sardjito hospital

RPD:
Alergi (-), DM (-), HT (-)
Stroke (-), Peny. Jantung (-), Peny. Ginjal (-),Asma (-)

Physical examination:
General condition: moderate, fully alert GCS E4V5M6
BP: 113/68mmHg
HR: 90x/mnt
RR: 20 x/mnt
S: 37°C
SpO2 99% on room air

Kepala:
Pupil isokor 3 mm/3 mm, CA (-/-), SI (-/-), RC (+/+), RK (+/+)

Upper face
I : simetris, VE (-) VL (-) hematoma (-), swelling (-), bleeding aktif (-)
P: sensoris dbn, NT (-), krepitasi (-)

Midface
I : asimetry , racoon eye (-/-), hematom (-), telekantus (-), diplopia (-), eye movement dbn, edema (-),
rhinorrhea (-) , bloody otorrhea (-), battle sign (-), deviasi septum nasi (-), step off (-), VE (-) , VL (+)
left zygoma region with size 2x1 cm, subcutaneous base, swelling (+)
P : sensoris dbn, floating maxilla (+), krepitasi (+), tenderness (+) on maxilla
Lower face
I : asimetrisdental avulsio (+), VE (-), VL (+) on mandibular symphysis with size 5x2x2 cm bone base, 
edema (-), deformitas (+) malocclusion (+)
P : sensoris dbn, NT (+), gliding mandibula (-), crepitation (+), tenderness (+)

Leher:
Jejas (-), JVP dbn, VE (-), VL (-)

Thorax:
I: Simetris (+), deformitas (-), jejas (-)
P: VF kanan = kiri
P: Sonor/sonor
A: Vesikuler (+/+), wheezing (-/-), ronkhi (-/-)

Abdomen:
I: Distended (+) bruise (+)
A: BU (-)
P: Hipertimpani (+)
P: defans muskular (+), tenderness (+) on whole abdominal region

Pelvis: pelvis stabil (+) NT (-)

Ekstremitas:
Akral hangat, CRT <2 detik, edema (-), lateralisasi (-)

Laboratorium:

Pkl 01.16
AL 16.84
Hb 14.3
Hmt 41.4
AT 385
PPT 17.1 / 14.8
APTT 32.9 / 31.2
INR 1.18
HbsAg negative
Alb 3.75
SGOT 171
SGPT 132
BUN 12.3
Creat 1.51
CRP <5
LDH 629
Na 143
K 4.02
Cl 106
GDS 130
Pkl 04.26
AGD
pH 6.670
HCO3 6.0
pCO2 52.1
pO2 106
Lac 17.05
SO2 85
BE <-30

AL 19.50
Hb 7.2
Hmt 22.9
AT 177

Pkl 05.17
AL 11.89
Hb 5.9
Hmt 19.4
AT 131
PPT 45.1/14.8
APTT 147.7/ 31.2
INR 3.46
Alb 1.56
SGOT 466
SGPT 550
BUN 13.8
Creat 2,73
Na 152
K 6.30
Cl 111

Urin :
Eritrosit 77.0 Leukosit 30.8 Bakteria 144.7

Assessment (usul):
- Fraktur Lefort I
- Fraktur segmental parasimfisis mandibula sinistra
- fraktur head condyle sinistra
- internal bleeding with unstable hemodynamic
- pneumoperitoneum e.c. hollow viscous perforation

Plan (usul):
Plan Digestif:
- pro Laparotomi Explorasi CITO

Plan Bedah Plastik:

- primary suture dengan Vicryl 4.0 dan nylon 5.0
- pro reconstruction of facial bone elektif jika KU membaik
RETROPERITONEAL ZONES
GASTRIC INJURY
GRADING