K/M/12yo

78.80.81
Chief Complaint : Pain on the right abdomen

It has been suffered since 1 week before admitted to Adam Malik

Hospital. Previously, the patient was fell at the yard and his
abdomen was hit by stone. History of loss of consciousness (-),
seizure (-). History of vomiting (+) since 3 days ago. History of
headache (-), bloody urine (-). Defecation (+), micturition (+)
normal. Patient was referred from district hospital.
 Present State
• Awareness : Alert
• TD : 110/70 mmHg
• HR : 98 beats/minute
• RR : 24 times/minute
• Temp : 36,9 0 C
• VAS :4
 Generalized State

• Head : No abnormality was found

• Neck : No abnormality was found
• Chest : No abnormality was found
• Abdomen : In localized state
• Genitalia : Male, no abnormality was found
• Extremities : No abnormality was found
 In localized State
• Abdomen :
 I : symmetrical, distention (-),
 A : bowel sound (+) decreased
 P : Tenderness (+) o/t (R) upper
quadrant and suprapubic,
muscular rigidity (-)
 P : Tymphani, liver dullness
(+)
• DRE : Perineum was normal, anal
sphincter tone was tight, pain (-),
smooth mucosal surface, ampula
recti was filled with feces.
Gloves: feces (+), blood (-), mucous (-).
Laboratory finding :
• Hb / Hct / WBC / PLT : 9,0/26/13.040/411.000
• Ur/Cr : 32/ 0,55
Chest X-Ray
FAST
• Hepatorenal pouch :
collecting fluid (-)
FAST
Splenorenal pouch :
collecting fluid (-)
FAST
Rectovesical pouch :
collecting fluid (+)
Working Diagnose :
Blunt Abdominal Injury with Anemia
Management at Emergency Room :
•Fasting
•IVFD Crystalloid  Ringer Lactate 20 drops/min
•Inj. Antibiotic  Inj. Cefotaxim 600 mg/12hrs
•Inj. Analgetic  Inj. Ketorolac 15 mg/8 hrs
•Insertion urine catheter, came out clear yellow 100 cc, UOP 30 cc/hr
•Hospitalized
•Observative Management
Plan :
•CT scan whole abdomen with oral & iv contrast