No.

Nam
: Mr. Is
e
21 years
Age :
old

Sex

: Male

No.
Reg

: 621696

Chief complaint

: Abdominal pain

History taking

: Suffered since 5 hours before admitted to the hospital

due to traffic accident. Bloody urinate (+) since
accident. Prior medical care at Maros hospital

Mechanism of injury : He was riding the motorcycle, suddenly he fell down

by himself and his body bumped to the ground
Injury sustain
Symptom & sign
Examination

: Right lower abdomen

: Pain, bloody urinate
: Physical examination, laboratory examination, USG
abdominal, chest x-ray, pelvis x-ray

PHYSICAL EXAMINATION
Primary Survey
A: Clear
B: RR: 20 x/minutes, spontaneous, symmetric,
thoraco abdominal type
C: BP: 110/70 mmHg, HR : 64 x/minutes, regular,
adequate
D: GCS 15 (E4M6V5), pupil equal 2,5 / 2,5 mm ,
LR +/+
E: T (ax) : 36,7oC

Secondary Survey
Right abdomen :
I: Seen flat, follow breath moving,
wound (-) , hematoma (+), skin
colour same with vicinity
A : Peristaltic (+) normal
P : Tenderness (+) at the whole
abdomen, defance (+)
P : Tympani (+)
Left lower flank
I: Seen excoriated wound size 3x3
xm, edema (-), hematome (-)

Urologycal states
Costovertebra region :
I : skin colour same with vicinity,
allignment normal,
gibbus (-) , edema (+), hematoma (+)
P : Tenderness (+) at right region abdomen
Suprapubic region :
I : bulging (-), wound (-), skin colour same
with vicinity,
P : Tenderness (-)

Genitalia external region

Perianal region :
I : Seen skin colour more darkness from
vicinity, hematoma (-), udema (-) , wound (-)
P : Tenderness (-)
Penis region :
I : Seen circumed, OUE normal, hematoma (-),
udema (-), meatal bleeding (-)
P : Tenderness (-)

Digital Rectal Examination

Sphincter was tight
Mucous was smooth
Ampulla was empty, mass tumour (-)
Gloves : blood (-), feces (+), slime (-)

Laboratory Result
WBC

: 21,6 x 103 / L

RBC

: 2,98 x 106 / L

HGB

: 8,4 g/dL

HCT

: 25,2 %

PLT

: 284 x103/ L

CT / BT

: 700 / 300

Blood Sugar : 96 mg/dl

Ureum

: 17 mg/dl

Creatinin

: 0,8 mg/dl

GOT / GPT

: 251/223 /L

Urinalisis
Colour

: red

lecosit sediment

: full

pH

: 7,0

eritrosit sediment

: full

Bj

: 1,020

glucose

: negative

urobilinogen : Normal
bilirubin

: Negative

keton

: +1/5

nitrit

: Positive

Blood

: +5/250

Lekosit

: +3/500

Chest X-ray

Pelvis X-ray

Abdominal CT Scan

Abdominal USG

WORKING
DIAGNOSIS

: Generalized peritonitis e.c

MANAGEMENT

: O2

suspect intraabdominal bleeding

due to suspect rupture of solid
organ

IVFD
Apply NGT
Blood transfusion
Medicaments
Report to senior digestive surgeon,
advice: immediately laparotomy
exploration
Report to senior urology surgeon,
advice: explore retroperitoneal cavity

Operating Procedure

Patient was lying in supine position under GA

Disinfection and draping procedure
Perform midline incision, deepen until peritoneum
Open peritoneum, seen blood approximately 500cc
Identificated solid organ liver and lien seen good
Identificated Hollow viscus organ from gaster to rectum ,
seen no perforation
Open white line identification Right Kidney
Seen completely shattered kidney (Right Kidney rupture
Grade V)
Fixate and ligation vasa renalis, continue with perform Right
Nefrectomy Kidney
Ligation the ureter and cut it until distal
Bleeding controle and performe 1 drain at cavum
retroperitoneal
Close wound layer by layer
Operation finished

POST OP
DIAGNOSIS

: Generalized peritonitis e.c

:
PROGNOSIS

FOLLOW UP

retroperitoneal bleeding
imbibition + rupture of kidney
grade V
Good

: Vital sign

Campbell-Walss Urology: 9th ed. 2007

Handbook of Urology; Diagnosis and Therapy 9th ed. 2007

Grading Renal Trauma

(Campbell-Walss Urology: 9th ed. 2007)

Practical algorithm in the acute treatment of renal trauma

(Genitourinary Trauma; Urology Clinic of North America, Elsevier Saunders 2006: p.17)