Patient Identity

• Name : M.Alfrizi Mahfud

• Age : 41 years old
• Sex : Boy
• Address : Darul Kamal, Aceh besar
• CM : 0-96-07-49
• Phone : 085361121200
• Admission time : 14.38 WIB
• Body weight : 20 Kg
 Time Response
Date/hour Exami Laboratory Radiology Hour Date/hour Supervisor
patient natio Examination Examination of patient
came to ER n Diagn out from
hour Send Result Send Result ostics ER

April 3th 14.40 14.50 15.00 15.10 OR dr.T..Yusriadi

2019 WIB WIB WIB WIB , Sp.BA
16.00
14.38 WIB
WIB
Chief Complaint
• Pain at the whole abdominal after trauma

Present illness history

• The patient was referred from Meuraxa Hospital with
chief complaint Pain at the whole abdominal after
trauma for 2 hours.
• Initially the patient was riding Bicycle and suddenly
struck by another from opposite of the stomach.
• There were no history of decrease of consciousness,
nausea and vomiting.
• There were history of nausea and vomiting.
• Patient open eyes spontaneously, motoric obeys
commands and good oriented verbal response to
time, place and person.
Physical examination
Primary Survey:
• A : Clear
•B : Spontaneous, 32 breaths/minute
Right haemithorax Left haemithorax
Symmetrical, there was no deviation of trachea, JVP in normal
Inspection
limit, lession at the right
Stem fremitus (+) ,pain (-) , Stem fremitus (+) pain (-)
Palpation
Emphysema Subcutaneous (-) Emphysema Subcutaneous (-)
Percussion Sonor Sonor
Vesicular, rhonchi (-), wheezing Vesicular, rhonchi (-), wheezing
Auscultation
(-) (-)

•C : BP : 80/60 mmHG, Pulse : 132 beats/minute,

cold extremity (+)  Urinary Catheter (with initial 20
cc clear  Resuscitation with IVFD RL 1000 cc
•D : GCS E4M6V5 = 15
• E : L/S at abdominal region
• I : Symmetrical, distension (+).
• A : Bowel sound (+) normal
• P : Pain (+) at the whole abdominal region, diffuse
abdominal tenderness (+)
• P : Thympani

Digital rectal examination

• Spinchter ani : Tight
• Mucosa : Smooth
• Ampula : Faeces
• Glove : Faeces (+), blood (-), mucus (-)
Secondary survey
• Head and neck  In normal limit
• Thorax
Right haemithorax Left haemithorax
Symmetrical, there was no deviation of trachea, JVP in normal
Inspection
limit.
Stem fremitus (+), pain (-) , Stem fremitus (+) pain (-)
Palpation
Emphysema Subcutaneous (-) Emphysema Subcutaneous (-)
Percussion Sonor Sonor
Vesicular, rhonchi (-), wheezing Vesicular, rhonchi (-), wheezing
Auscultation
• Abdominal (-) (-)
L/S at abdominal region
• I : Symmetrical, distension (+) minimal, lession (+) at the
whole region
• A : Bowel sound (+) normal
• P : Pain (+) at the whole abdominal region, diffuse
abdominal tenderness (+)
• P : Thympani
• Pelvic region  in normal limit
• Upper extremity  in normal limit
• Lower extrimity  in normal limit
Assessment:
1. Blunt abdominal injury with unstable hemodynamic
Management
• Stop oral intake
• NGT decompression  Clear
• IVFD RL 2000 cc/24 hours  maintenance after
resuscitation
• Ceftriaxone inj. 500 mg
• Ketorolac inj. 10 mg
• Laboratory examination
• Radiology examination
 Vital Sign and Urine Output

Hours
BP (mmHg) HR (x/i) RR (x/i) T (oC) Urine (CC)
(WIB)
15.00 80/60 132 24 36.8 18
16.00 90/70 126 22 36.4 20
Laboratory result
• Hemoglobin : 9,1 g/dL  transfusion
• White Blood Count : 10.00/µL
• Platelets : 180.000/µL
• Hematocrit : 30 %
• PT : 10.6 minutes
• APTT : 21.7 minutes
• Glucose ad Random : 155 mg/dL
Diagnosed:
• Internal bleeding due to susp. solid organ rupture due
to blunt abdominal injury with unstable
hemodynamic (ICD 10 CM K92.2)

Consult to Digestive Surgery division:

• Laparotomy exploration emergency
Operative Report
• Performed midline incision.
• Peritoneum was open, flew out blood cloth 2000 cc
 evacuation
• Performed packing at liver
• Patient arrest  performed CPR by anesthesiologist
but no response
• Patient passed away at the operating room
Post Operative Diagnosed
Post laparotomy exploration due to:
• Internal bleeding due to liver rupture AAST grade V
due to blunt abdominal injury with unstable
hemodynamic (ICD 10 CM K92.2)