DUT Y

REPORT

D E C E M B E R 2 0 TH- 2 1 TH 2 0 1 6

IDENTITY

• Name : Mr. G N
• Age : 24 y.o
• Sex : Male
• Address :Tarus
• Date : Jan 22th 2017 21.45 WITA

• Chief Complaint : Swelling in testis • Mechanism of Injury : • Patient came accompanied by family due to accident while working one and half an hour before entering ER. The patient then immediately carried to hospital. Patient complaining severe pain above the pubic bone. The patient was hit by tractor in groin area and the scrotum getting swelling. • Patients deny bleeding. and wasn’t unable to urinate. after the accident. .

haematome in inguinal D regio. GCS E4V5M6 –E : swelling in scotum apprx 7. –C : P : 96x/m. BP : 100/70 mmHg –D : Somnolen. clear –B : thoracal. 24x/minute.PHYSICAL EXAMINATION • Primary Survey : –A : Patent. .5x12.5cm.VL in right side scrotum 2x3cm.

SECONDARY SURVEY • Head : – Hematom (-). conjuntiva anaemic (-). discharge (-) . – Nose : bleeding (-) – Mouth : in normal condition – Ear : bleeding (-). normocephal – Eye : Pupil isocor (+/+) Ø 3/3mm.

mass (-). venous dilatation (-). krepitasi (-) • Percusion : sonor (+/+) • Auscultation : Vesiculer (+/+) . gallop (-) . murmur (-). Ronchi (-/-). Wheezing (-/-) • Heart: – S1/S2 single. • Palpation : Vocal fremitus (R=L).PHYSICAL EXAMINATION • Lung • Inspection : Chest expansion symetric.

 Auscultation : peristaltic sound normal  Palpation:  flexible. Tenderness (-)  Percussion :  Tympanic .PHYSICAL EXAMINATION  Abdomen  Inspection: Flat.

5 x 12. vulnus laceratum at base right scrotum size 2 x 3 cm .Secondary survey :  Pelvic : swelling at scrotum size ± 7. 5 cm .

capilarry refill time < 2 second .  Look : vulnus -  Feel : warm. Extremities  Tigh : normal findings  Cruris .

– Swelling in scrotum – Haematome in inguinal sinistra regio. LOCALIZED STATE • Pelvic. – VL in lateral dextra .

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LABORATORY Blood Routine : • Hb  10.22 x 10^3/uL • Platelet  225 x 10^3 /uL • Glukosa  179 mg/dL .88 x 10 ^6/uL • WBC  26.7 g/dL • RBC  3.

ASSESMENT • Pelvic Haematoma .

PELVIC X-RAY .

1 amp • Ranitidine inj. 1gr • DC catheter • Vital sign observation .THERAPY • IVFD RL • Ketorolac inj. 1 amp • Ceftriaxone inj. 1 amp • Kalnex inj.