EMERGENCY CASE REPORTS

Monday, February 17 th 2020

SURGERY DEPARTMENT

EMERGENCY ROOM
Wahidin Sudirohusodo General Hospital
Makassar
EMERGENCY CASE REPORT
Monday, February 17 th 2020
Ambulation : 1 Patient
Hospitalized
: 8 Patients

Observation : - Patient
Operated : - Patient
Death : - Patient
Total : 9 Patients
Wahidin Sudirohusodo General Hospital
Makassar
 Nama : Tn. M Umur : 17 tahun
RM : 911372 DPJP : dr. SM

Keluhan Utama : Abdomen feels bloated

Riwayat Penyakit : Had been experienced since 3 days ago before being
Sekarang admitted to the hospital. Accompanied by abdominal pain,
especially at the upper right abdomen. There was no fever,
no vomiting. Normal defecation, normal urination. The
patient had an accident 2 weeks ago and the patient was
treated at Luwuk Regional Hospital for 2 weeks with a
diagnosis of blunt abdominal trauma with ruptured liver
rupture. He had 3-bags transfusion before.
Mekanisme Trauma : The patient was riding a motorcycle without wearing a
helmet. The patient fell down and the abdomen hits
the handlebar.
PHYSICAL EXAMINATION

Primary Survey
A: Clear
B: RR: 20 x/minutes, spontaneous, symmetric,
vesicular respiratory sounds
C: TD 120/80 mmHg, Heart rate: 90 x/menit,
regular, adequate.
D: GCS 15 (E4M6V5), pupil equal Ø 2.5 mm / Ø 2.5
mm , LR +/+
E: T : 36,8 °C
 SECONDARY SURVEY
EYES
Anemic Conjunctiva -/-
Sclera Icteric +/+
SECONDARY SURVEY
Abdomen
I : convex, follows breathing,
dam et regio right
hypochondria and right
lumbar, darm contour and
darm steifung was absent.
A: Normal peristalsis
P : Hypochondrial and lumbar
right tenderness.
P : Tympani, heart deaf (+),
right hypochondrial knocking
pain
Rectal toucher :
The anal sphincter suffocates, the
mucosa is slippery, the ampulla
contains feces.
Handscoon:
Stool (+), blood is absent, mucus
is absent.
 Clinical Diagnosis

 Blunt abdominal trauma with stable hemodynamic

THORAX RO
RESULT:
• Subcapsular hematoma with grade IV liver
rupture
• Grade II lien laceration
• Intraperitoneal free fluid density
 Laboratorium
• WBC 12.200 • GDS 84
• RBC 3.77 • UR 33
• HGB 11.2 • CR 0.66
• HCT 34 • SGPT 79
• PLT 1084 • SGOT 99
• Bil total 4.65 • Albumin 2.7
• Bil direct 2.8 • ELECTROLIT
– Na 136
– K 5.0
– Cl 106
DIAGNOSIS :  Blunt abdominal trauma with stable
hemodynamic
 Grade IV liver rupture
 Grade II splenic rupture
 TATALAKSANA
• IVFD
• O2 NK 3lpm
• NGT
• URIN CATHETER
• MEDICAMENTOSA
• OBSERVATION VITAL SIGNS, ACUTE
ABDOMENT SIGNS
• PLAN FOR CT ANGIOGRAPHY
Algoritma Trauma Tumpul
Abdomen