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    Bab 3 Case Report

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    Ulil Amri Pramadani
    This case report summarizes the medical case of a 21-year-old male construction worker who was injured at work when struck by a glass fitting machine. He presented to the emergency department complaining of left upper abdominal pain. Examination found bruising and excoriations on his back and left flank with abdominal tenderness. Imaging revealed internal bleeding in the abdomen consistent with a splenic injury. The patient was admitted and treated conservatively with IV antibiotics and fluids. His other scans and examinations were normal.

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    Bab 3 Case Report

    Uploaded by

    Ulil Amri Pramadani
    25 views11 pages
    This case report summarizes the medical case of a 21-year-old male construction worker who was injured at work when struck by a glass fitting machine. He presented to the emergency department complaining of left upper abdominal pain. Examination found bruising and excoriations on his back and left flank with abdominal tenderness. Imaging revealed internal bleeding in the abdomen consistent with a splenic injury. The patient was admitted and treated conservatively with IV antibiotics and fluids. His other scans and examinations were normal.

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    dtdtydu

    Original Title

    6 BAB 3

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    This case report summarizes the medical case of a 21-year-old male construction worker who was injured at work when struck by a glass fitting machine. He presented to the emergency department complaining of left upper abdominal pain. Examination found bruising and excoriations on his back and left flank with abdominal tenderness. Imaging revealed internal bleeding in the abdomen consistent with a splenic injury. The patient was admitted and treated conservatively with IV antibiotics and fluids. His other scans and examinations were normal.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    25 views11 pages

    Bab 3 Case Report

    Uploaded by

    Ulil Amri Pramadani
    This case report summarizes the medical case of a 21-year-old male construction worker who was injured at work when struck by a glass fitting machine. He presented to the emergency department complaining of left upper abdominal pain. Examination found bruising and excoriations on his back and left flank with abdominal tenderness. Imaging revealed internal bleeding in the abdomen consistent with a splenic injury. The patient was admitted and treated conservatively with IV antibiotics and fluids. His other scans and examinations were normal.

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    BAB 3

    CASE REPORT

    Preceptor : Dr. dr. Bambang Arianto, Sp.B, FINACS

    A. PATIENT IDENTITY

    Name : Mr. Arief Hidayat H.

    Age : 21 Years Old

    Address : Prampelan, Magetan

    Job : Employee of Building Construction TATA

    Last education : Senior High School

    Register number : 796215

    Time of Injury : 25 January 2017, 15.00

    Coming to emergency department : 25 January 2017, 15.20

    Hospitalized IC/D5 : 25 Januari 2017, 22.00

    B. SUBJECTIVE

    1. PRIMARY SURVEY

    Airway : Corpus alenium (-), Maksilofacial trauma (-), Additional breath,

    sounds (-), gaps (-)

    Breathing : spontaneously, symmetric, RR: 24 x/minute

    Circulatiom : HR : 94 x/minute

    Blood pressure : 110/60 mmHg

    CRT < 2 detik

    SpO2 : 100 %

    Disability : GCS : 456

    Round pupil isokor 3mm/3mm, Light reflex +/+

    33
    Exposure :Excoriation on back sinistra and hematome on flank sinistra,

    bleeding (-), bone exposed (-)

    2. SECONDARY SURVEY

    Main complaint :

    Pain on upper left abdominal area

    HISTORY OF PRESENT ILLNESS :

    Patient come to the Emergency Department of Surabaya Haji Hospital with

    complain of upper left abdominal pain. Upper left abdominal pain felt after

    struck by fitter glass machine while working twenty minutes ago. When strucked

    by, the patient face down and heavy equiment on the heads and backs of the

    patients. There is a wound in the head, back and mark bruise above his left waist,

    pain (+), wound in the head was stitching in the Emergency Room. Patient

    conscious well and can telling detail chronology of injury. Headache (+), nausea

    (-), vomiting (-), seizures (-), urinate and defecate normally.

    HISTORY OF PAST ILLNESS:

    History of such illness is denied, history of any operation in abdomen is denied,

    allergy of food and/or medicine is denied.

    SOCIAL HISTORY :

    The patient is an employee at Building Construction TATA, work 6-8 daily

    hours, patient have last on meal 3 hours ago

    3. GENERAL STATE :

    General state : Weak, Weight: + 60 kg

    Tax : 37 oC

    Head/Neck : Anemis (+) /Ikteric -/Cyanosis -/Dyspnea-

    34
    Thoraks

    I : Normochest, symmetric, retraction (-)

    P : Movement of the chestwalls symmetric, crepitation (-), deviated trachea

    (-), widened intercostals space (-)

    P : sonor/ sonor

    A : breath sounds vesicular +/+, Ronchi -/-, Wheezing -/-

    COR

    I : Ictus does not seem

    P : Ictus no palpable, thrill (-)

    P : heart border normal

    A : S1S2 single, Gallop (-), Murmur (-)

    Abdomen

    I : Flat simetris, lesion on flank sinistra, hiperemi (+), hematome (+), swelling

    (-), vulnus (-), bleeding (-), bone exposed (-)

    A : bowel sounds (+) weak

    P : Soepel, tenderness (-), H/L/R no palpable, pain


    - + +

    - - +

    - - -

    P : Meteorismus (-), timpani (+), dull on hypocondrium sinistra

    Ekstremitas :

    o Warm akral

    + +

    + +

    35
    o Oedema
    - -

    - -

    o Cyanosis

    - -

    - -

    o CRT < 2 dtk

    4. LOCALISE STATE

    Regio Thoraks posterior :

    Excoriation et regio thoraks posterior sinistra, bleeding (-), pain (+), bone

    exposed (-)

    hematome at regio flank sinistra (+), pain (+), vulnus (-)

    5. DIAGNOSIS

    Suspect blunt abdominal trauma + Vulnus excoriatum et regio thoraks

    posterior + COR

    6. PLANNING DIAGNOSIS: -

    - R Cervical Ap/Lat

    - R Thoraks Ap/Lat

    - R L/S Ap/Lat

    - USG FAST Abdomen

    - CT scan skull axial non contras

    - DL serial/2jam

    36
    7. PLANNING THERAPY

    - Consult to general surgeon

    - 2 line infusion RL

    - Inj Ceftriaxone 2 x 1 gram iv

    - Inj. Antrain 3 x 500 mg iv

    - Inj Ranitidin 2 x 50 mg i

    - Inj. Tetagam

    - Inj. Piracetam 3 x 3 g

    - Set abdominal circumferential

    8. PLANNING MONITORING

    - General state

    - Patient complaint

    - Vital sign observation/15 minutes

    - Abdominal circumferential observation/2 hours

    The picture of patient:

    37
    38
    39
    USG Abdomen :

    hipoecoic lesion border not spesific up to middle pole, look like much fluid

    (internal bleeding) on morison pouch, perilienal, pervesica and subdiaphragma

    with conclusion internal bleeding et causa splenic injury

    R Cervical Ap/Lat : normal

    R Thoraks Ap/Lat : normal

    R L/S Ap/Lat : normal

    CT SCAN skull axial non contrass : like mild edema cerebri, intracranial bleeing

    (-), midline shift (-), fraktur (-)

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