Patient identity

Name
: Munawar
Age
: 27 years old
Sex
: Male
Address
: Mns Ara Kec. Kaway
XVI
Kab. Aceh Barat
CM : 1 06 24 92
Phone
: 082363590011
Admission time
: 04.33 AM

Time Response
Date/ho
ur
patient
came to
ER

Examina
tion
hour

August 27th
2015
04.30

04.33

Laboratory
Examination

Radiology
Examination

Send

Result

Send

Resul
t

05.00

05.45

05.30

06.00

Hour of
Diagnos
tics

06.00

Date/ho
ur
patient
out
from ER

DPJP

Dr.dr.
Azharu
ddin.
Sp.OT.K
.Spine

Chief Complaint:
Cant move af the lower extremity
Present illness history
Patient came to Zainoel Abidin
emergency
room
with
a
chief
complaint Cant move at the lower
ekstremity for 12 hours ago. Initially,
he was crushed by steel when he was
work at the a factory. There was
history of nausea and vomiting . There
was no history loss of consciousness.

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 (+),defans muscular (+)
P: thympani (+), liver dullness (+)

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 (+),defans muscular (+)
P: thympani (+), liver dullness (+)

Neurologic examination
5555 5555
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VAS : Moderate

Mild 1-3
Non opioid +
adjuvant
- COX-2
- Ibuprofen
- Aspirin
Acetaminophen

Moderate 4-6
Opioid +
nonopioid +
adjuvant
-Codein
-Propoxyphene
-Hydrocodone
-Tramadol

Severe 7-10
Opioid +
nonopioid +
adjuvant
-Oxycodone
-Morphine
-Hydromorphon
e
-Fentanyl

Assessment:
1.Dislocation fracture vertebra lumbal
1-2 with frankel B
2.Susp blunt abdominal injury with
stable haemodinamic

Management

O2 - 10 litre via face mask

IVFD RL 20 drips/min
Neck collar
NGT decompresi
Urine catheter
Metyl prednisolone Drip. 2100 cc for 1 hours
Ceftriaxone Inj. 1 g
Ketorolac Inj. 30 mg
Ranitidin Inj. 50 mg
Catheter urinary
Laboratory examination
Radiology examination

Laboratory result
Hemoglobin
: 15.6 gr/dl
White Blood Count : 9.000 / ul
Platelets
: 166.000/ul
Hematocrit
: 45 %
CT/BT
: 8/2

Radiologi result
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
2.Blunt abdominal injury with stable
haemidinamic (ICD 10 CM
3.Peritonitis ec susp perforasi hollow
organ (ICD 10 CM

Consult to orthopedic division:

Hospitalize
MRI Spine
Logg roll /2 hours
Posterior decompression + stabilization
elective
Consult to Digestive Surgery
division:
Laparotomi Eksploration emergency

Follow up
Date
26/8/2015
AD 1

O
Pain
General Condition : 1.
(+) at good
the
BP : 130/80 mmhg
abdom Pulse : 80x/minute
inal
RR
: 20x/minute
2.
region L/S at the
abdominal region :
I :
symetrically,
distension (-), 3.
hematoma (+)
A: bowel
sound (+)
P: pain
(+),defans
muscular (+)
P: thympani
(+), liver
dullness (+)
Neurologic

A
Dislocation
fracture of the
VL1-2 frankel
B (ICD 10 CM
Blunt
abdominal
injury with
stable
haemidinamic
(ICD 10 CM
Peritonitis ec
susp perforasi
hollow organ
(ICD 10 CM

P
O2 - 10 litre via
face mask
IVFD RL 20
drips/min
Neck collar
NGT decompresi
Urine catheter
Metyl prednisolone
Drip. 2100 cc for
1 hours
Ceftriaxone Inj. 1
g
Ketorolac Inj. 30
mg
Ranitidin Inj. 50
mg
Patien
reffuse
medical advise