 Name : Mr.

Ahmad Rizal
 Age : 19 years old
 Sex : Female
 Address : Baruga
 Occupational : Student
 Admission : December, 18th 2018 (22.30)
 Doctor in charge : dr. Syamsul Rijal, Sp.B
 HISTORY TAKING

 Chief Complain : Right Chest pain

 Anamnesis :
Patient came to hospital with pain at the face since 30 minute ago
after a traffic accident.
 Mechanism of Trauma
The patient is riding a motorbike at medium speed without using a helmet,
then the patient bumps into the sidewalk when the patient turns his motorbike
to the right. other mechanisms are unknown
 History Of Trauma
 There was history of syncope (+), nausea (-) and vomiting (-)
 There was history of previous medication (-)
A Clear, Cervical Spine Control

B Respiratory rate 20x/m, spontaneous,

thoracoabdominal type, symmetric

C Blood Pressure 110/70 mmHg

Pulse 86x/m, regular, strong

Glasgow Coma Scale (E4M6V5),

D Isochoric pupil, Ø 2,5 mm/2,5 mm,
Light reflex +/+

E Temperature 36,6OC/Axillary
 Composmentis,
Moderate illness,
Good nourish
 Ears : Within normal limits
Head : Within normal limits Neck : Within normal limits
Face : Within normal limits Chest : Localized Stase
Eyes : Within normal limits Abdomen : Localized stase
Nose : Within normal limits Stomach : Within normal limits
Mouth : Within normal limits Upper Limb: Within normal limits
Lower Limb: Within normal limits
 RIGHT THORAKS REGION
Inspection:
Deformity (-), hematom (-), Sweeling ()
wound(+) Vulnus excoriatum, Jejas (+)
Palpation
Tenderness (+) at the wound
Perkusi
Sonor (+/+) RIGHT HYPOCONDRIUM REGION
Auskultasi Inspection :
Bronchovesicular, Ronkhi (-), wheezing (-). Deformity (-), hematom (-), Sweeling () wound(+)
Vulnus excoriatum, Jejas (+)
Auscultation :
Peristaltik (+) within normal limit
Palpation :
Tenderness (+)
Percution :
Thympani
Clinical finding
 Rountine
Blood
Count Test

USG
ABDOMEN
 Laboratorium Finding

Value Refference
Value
WBC 11,22 103/uL 4,00-10,00
Value Refference
RBC 4,31 106/uL 4,00-6,00 Value
Hb 12,3 g/dl 12-16 GDS 102 Mg/dl 70-180
Neut 8.70 103/uL 1.50- 7.00 Ur 23 Mg/dl 19-44
PLT 246 103/uL 150-400 Cr 0,9 Mg/dl 0,7-1,2
SGOT 548 U/L 548
Value Refference Value
SGPT 717 U/L 717
CT 3’05’’ 6-12 minutes
BT 11’20’ ≤ 3 minutes
USG ABDOMEN

KESAN :
• USG Fas positif
(19/12/2018 pukul 12.00
WITA.
• Intraparenchymal liver
hematoma (AAST Grade II)
• Organ abdomen lain tak
tampak kelainan.
DIAGNOSED TCR + Trauma Ginjal
 MANAGEMENT

Antibiotic

Analgetic

CONSULT GENERAL
SURGERY IVFD

H2RA

Antihemoragic