No.

Name : Mr. B Sex : Male

Age : 52 years old No. Reg : 640691

Chief complaint :
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 : He was riding the motorcycle, suddenly he fell down
injury by himself and his body bumped to the ground
Injury sustain : Right lower abdomen
Symptom & sign : Pain, bloody urinate
Examination : 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 suspect
intraabdominal bleeding due to suspect
rupture of solid organ

MANAGEMENT : O2
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 retroperitoneal
bleeding imbibition + rupture of kidney grade
V
PROGNOSIS : Good

FOLLOW UP : Vital sign

 Campbell-Walss Urology: 9th ed. 2007

Handbook of Urology; Diagnosis and Therapy 9 th 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)