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Case Report

14 years boy brought to E.R. with a blunt pain on the abdominal


surface (referred from Ungaran Hospital with blunt abdominal trauma
suspect renal rupture), equipped with IV infusion, urine catheter 14 fr,
and they brought a X-ray photo.
Primary Survey
Airway:
Alert (+)
Snorring (-)
Gurgling (-)
Speak fluently (+)
Patent Airway mask O2 10 L/min

Breathing :
RR = 20 x/mnt
trachea on the midline
JVP increased (-)
Thorax : lesion (-)

: static symmetric
dynamic symmetric
P
: tactile fremitus was equal on both side
P
: sonor on all area
A
: basic sound was vesicular, no additional

sound
SpO2 : 99 %
Adequate Breathing
Circulation & Hemorrhage Control:
HR : 86 x/min (adequate pressure)
BP : 145/86 mmHg
External bleeding (-)
Blood sampling

Disability :
GCS E4M6V5 = 15
Pupil isokor 3 mm, RC +/+
Exposure :
Log roll : lesion (+) on the left flank
Regio antebrachii sin distal :
I
: deformities angulation (+), malrotation (-), shortening (-), edema
(+), open wound (-)
P
: pain on pressure (+), axial pain (+), radial artery palpation (+), ulnar
artery (+), capp refill <2

Secondary survey
6 hours before admitted to the hospital, the patient is climbing a
fruit-bearing tree, and suddenly fal from the tree from 6 metres height,
the patient was fallen with left sideway position, his left hand hold the
body from the fall. After the accident, the patient was staying awake,
unconscious (-), nausea (-), vomit (-) and then patient was brought to
the RSUD Ungaran. On the RSUD Ungaran, the patient was checked,
equipped with IV infusion, and because of limited medical personnel,
patient was referred to RSDK.
Physical examination :
General appearence: conscious
TV : BP
: 145/86 mmHg
HR
: 86 x/min
RR
: 20 x/min
t
: 37,2C

Head/neck
Conj.palp was not anemic
Shunken eyes -/Dry lips (-)
Chest :
Heart
:
I
:
IC was not seen
P
:
IC was palpable at 5th ICS, 2 cm medial to Mid
Clavicle Line
P
: configuration w.n.l
A
: pure heart sound, no murmur
Lung
:
I
: static symmetric
dynamic symmetric
P
: tactile fremitus was equal on both side
P
: sonor on all area
A
: basic sound was vesicular, no additional sound

Abdomen :
I
: flat, lesion (+) on the left flank
Pa
: Distended (+), NT (+), DM (-)
Pe
: Tymphany, side dullness (+)N, shifting dullness (-),
hepatic dullness (+)
A
: intestinal sound (+) N
Pelvic : lesion (-) stable
External genitalia : male, normal. DC 14 fr 40 cc/hours production
red cloudy
Extremity
Cyanosis
Cold akral
Capp. Refill
Motor
Sensory

Supor
Infor
-/-/-/-/<2/<2
<2/<2
5-5-5/ (trbts nyeri) 5-5-5/ 5-5-5
dbn
dbn

Local Status
Regio antebrachii sin distal :
I: deformities angulation (+), malrotation (-), shortening (-), edema
(+), open wound (-)
P: pain on pressure (+), axial pain (+), radial artery palpation (+), ulnar
artery (+), capp refill <2

Diagnosis:
Abdominal blunt trauma with stable hemodynamic, suspect renal
rupture
Left antebrachii fracture 1/3 distal, closed, non complicated

Laboratorium (2-9-2013 pk. 19. 32)


Hb
: 7,6 gr %
Ht
: 22,3 %
Leukocyte : 14.200/mmk
Thrombocyte: 234.000/mmk
PPT/K
: 17,4/14,6 det
APTT/K
: 33,8/33,2 det
Lactate
: 3,7 mmol/L

GDS
Ur
Cr
Na
K
Cl

: 166 mg/dl
: 15 mg/dl
: 0,9 mg/dl
: 140 mmol/l
: 3,5 mmol/l
: 107 mmol/l

radiology:
X- ray Cervical AP Lat
X- ray Thorax AP
X-ray Antebrachii sin AP-Lat (RSUD Ungaran)
MSCT Abdominopelvical with contrast

Diagnosis:
Abdominal blunt trauma with stable hemodynamic e.c left renal
rupture grade IV, spleen rupture grade II
Left radius fracture1/3 distal transv displ closed non-complicated

MANAGEMENT :
- Informed consent
- Infusion RL 20 drip/min
- Transf PRC 250 cc
- Inj Ceftriaxon1 gr iv
- Inj Ranitidin 50 mg iv
- Pro Laparotomy exploration + Pro close reposition

Diagnosis:

Abdominal blunt trauma with stable hemodynamic e.c left renal rupture grade IV, spleen
rupture grade II

Left radius fracture 1/3 distal transv displ ttp nk, Fr. Radius sinistra 1/3 distal transv displ
closed non complicated

Post laparotomy exploration + partial nephrectomy

Post ORIF + circular gyps on the left antebrachial


HCU