CASE REPORT

Tuesday, August 4th 2015

Team on duty
dr. M. Nazir Tambunan
dr. Tommy Rivelino
dr. Andri Mulia
dr. Bobby HE Fermi
dr. Herdi Gunanta S
dr. Syahmardani Ibnu
1. Patient identity
Name
Age
Sex
Address
CM
Phone
Admission time

(Jaga 1)
(Jaga 2)
(Jaga 3)
(Jaga 4)
(Jaga 5)
(Jaga 6)

: Munawar
: 27 years old
: Male
: Mns Ara Kec. Kaway XVI Kab. Aceh Barat
: 1 06 24 92
: 082363590011
: 04.33 AM

Date/h Examinati Laboratory

Radiology
Hour of
our
on hour
Examination Examination Diagno
patien
stics
t came
Sen Result Send Result
to ER
d
August
27th
2015
04.30

04.33

05.00 05.45

05.30 06.00

Date/ho DPJP
ur
patient
out from
ER
Dr.dr.
Azharudd
in Sp.OT
K Spine

2. Chief complaint
Can not move of the lower extremity
3. Patient illnes history
Patient came to Zainoel Abidin emergency room with a chief complaint can not
move of the lower extremity for 12 hours ago. Initially, he was working at the a
factory and then his body struck down by steel construction. There was no
history loss of consciousness. Patient had performed radiology examination

4. Physical examination

Primary Survey
Airway
: Clear, with C Spine Control
Breathing
: Spontaneous, 20 breaths/min
Circulation : Blood Pressure: 110/70 mmHg, HR: 76 beats/min
Disability
: GCS E4M6V5: 15
isochoric pupil, lateralization (-)
L/S at the abdominal region :
I : symetrically, distension (-), hematoma (+)
A: bowel sound (+)
P: pain (+), muscular rigidity (-)
P: Thympani (+), liver dullness (+)

Digital Rectal Examination

Loose sphincter ani, Bulbocavernosus reflex (-), smooth mucose
Ampula recti faeces empty
Glove : faeces (+), blood (-), mucous (-)
Neurologic examination
5 5
1 1
Sensoric : +
Secondary survey :
Head in normal limit
Neck in normal limit
Thorax
in normal limit
Abdomen
L/S at the abdominal region :
I : symetrically, distension (-), hematoma (+)
A: bowel sound (+)
P: pain (+), muscular rigidity (-)
P: Thympani (+), liver dullness (+)
Neurologic examination
5 5
1 1

5. VAS

o
Assessment:
1. Dislocation fracture vertebra lumbal 1-2 with frankel B
2. Blunt abdominal injury with stable haemodynamic

Management
O2 10 litre via face mask
IVFD RL 20 drips/min
Neck collar
NGT decompression
Urine catheter
Metylprednisolone drip 378 mg / 24 hours
Ceftriaxone Inj. 1 g
Ketorolac Inj. 30 mg
Ranitidin Inj. 50 mg
Laboratory examination
Radiology examination

6. Laboratory examination
Hemoglobin
: 15.6 gr/dl
White Blood Count : 9.000 / ul
Platelets
: 166.000/ul
Hematocrit
: 45 %
CT/BT
: 8/2
7. Radiology examination
Thorax AP :
In normal limit
Thoracolumbal AP/lat :
There was Dislocation fracture of the Vertebra L1-2
FAST :
There was free air in the Morrison pouch

Diagnose
1. Dislocation fracture of the VL1-2 with frankel B (ICD 10 CM xxxxx)
2. Susp. rupture solid organ due to blunt abdominal injury with stable
haemodynamic (ICD 10 CM xxxxx)

Consult to orthopedic division:

Hospitalize
MRI Spine
Log roll /2 hours
Posterior decompression + stabilization elective

Consult to Digestive Surgery division:

Laparotomy Exploration emergency
CT scan abdomen contras non contras

Follow Up

Date

26/8/2015 Pain
General Condition : good
AD 1
(+) at theBP : 130/80 mmhg
abdomina Pulse : 80x/minute
l region RR
: 20x/minute
L/S at the abdominal
region :
I : symetrically,
distension (-),
hematoma (+)
A: bowel sound (+)
P: pain (+),defans
muscular (+)
P: thympani (+), liver
dullness (+)
Neurologic examination
5
5
1
1

1. Dislocation
O2 - 10 litre via face mask
fracture of
IVFD RL 20 drips/min
the VL1-2
NGT
with frankel B Urine catheter
(ICD 10 CM
Metyl prednisolone Drip.
xxxxx)
378 mg maintenance
2. Susp. rupture Ceftriaxone Inj. 1 g
solid organ
Ketorolac Inj. 30 mg
due to blunt Ranitidin Inj. 50 mg
abdominal
Patient
refuse
medical
injury with
advise
stable
haemodynam
ic (ICD 10 CM
xxxxx)