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    24042016-mr.G-39 Years Old-Mild Head Injury GCS 15+peritonitis Sup. Rupture Lien Ec Blunt Abdominal Trauma-Dr. Syamsul Rijal, SP.B

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    Jeanet Prisilia
    1. The 39-year-old male patient was admitted to the hospital on April 24th, 2016 after a traffic accident one day prior where he was hit by a dog while riding his motorcycle without a helmet. 2. He reported abdominal pain for 5 hours prior to admission and also experienced bleeding from his ear and nose as well as headache after the accident. 3. His initial examination and lab work showed mild head injury, peritonitis, and a possible ruptured spleen based on abdominal blunt trauma from the accident. Further tests, surgery consultation, IV fluids, antibiotics and analgesics were planned.

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    24042016-mr.G-39 Years Old-Mild Head Injury GCS 15+peritonitis Sup. Rupture Lien Ec Blunt Abdominal Trauma-Dr. Syamsul Rijal, SP.B

    Uploaded by

    Jeanet Prisilia
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    1. The 39-year-old male patient was admitted to the hospital on April 24th, 2016 after a traffic accident one day prior where he was hit by a dog while riding his motorcycle without a helmet. 2. He reported abdominal pain for 5 hours prior to admission and also experienced bleeding from his ear and nose as well as headache after the accident. 3. His initial examination and lab work showed mild head injury, peritonitis, and a possible ruptured spleen based on abdominal blunt trauma from the accident. Further tests, surgery consultation, IV fluids, antibiotics and analgesics were planned.

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    24042016-mr.G-39 years old-mild head injury GCS 15+peritonitis sup. rupture lien ec blunt abdominal trauma-dr. syamsul rijal, Sp.B

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    1. The 39-year-old male patient was admitted to the hospital on April 24th, 2016 after a traffic accident one day prior where he was hit by a dog while riding his motorcycle without a helmet. 2. He reported abdominal pain for 5 hours prior to admission and also experienced bleeding from his ear and nose as well as headache after the accident. 3. His initial examination and lab work showed mild head injury, peritonitis, and a possible ruptured spleen based on abdominal blunt trauma from the accident. Further tests, surgery consultation, IV fluids, antibiotics and analgesics were planned.

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    8 views13 pages

    24042016-mr.G-39 Years Old-Mild Head Injury GCS 15+peritonitis Sup. Rupture Lien Ec Blunt Abdominal Trauma-Dr. Syamsul Rijal, SP.B

    Uploaded by

    Jeanet Prisilia
    1. The 39-year-old male patient was admitted to the hospital on April 24th, 2016 after a traffic accident one day prior where he was hit by a dog while riding his motorcycle without a helmet. 2. He reported abdominal pain for 5 hours prior to admission and also experienced bleeding from his ear and nose as well as headache after the accident. 3. His initial examination and lab work showed mild head injury, peritonitis, and a possible ruptured spleen based on abdominal blunt trauma from the accident. Further tests, surgery consultation, IV fluids, antibiotics and analgesics were planned.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 13

    IDENTITY

    Name : mr. G
    Age : 39 years old
    Address : Ereke
    Admission : April 24th, 2016
    DPJP : dr. H. Syamsul Rijal,
    Sp.B

    HISTORY TAKING
    (HETEROANAMNESIS)
    Chief
    Complain : abdominal pain
    Anamnesis: suffered since 5 hours before
    admitted
    to the hospital after a traffic
    accident one day ago. Initially pain in the
    upper abdomenand then pain is felt
    throughout the abdomen. Mechanism of
    trauma : Patient was riding his motorcycle
    with moderate, patient wa not using his
    helmet, he was hit the dog, patients were
    then falling from his motorcycle.

    History of syncope unknown, history of


    vomiting (-), history of bleeding from the
    left ear and nose (+), history of headache
    (+), history does not urinate after accident.
    The patient referred from Kalesusu PHC
    and received treatment: IVFD 2 kolf,
    Tranecxamid Acid Inj, Ketorolac Inj,
    Neurosambe Inj, Ceftriaxone Inj, Ranitidin
    Inj, Dexametason Inj.

    General Situation

    PHYSICAL EXAMINATION

    Next...

    CLINICAL FINDING

    LABORATORIUM FINDING

    COUNTING BLOOD CELLS


    WBC 25.62 [10^3/uL]
    HGB 8.2 [g/dL]
    HCT 24.3 [%]
    PLT 157 [10^3/uL]
    NEUT : 21.79 [10^3/uL] 85.2 [%]

    Clinic
    al
    Diag
    nose

    MILD HEAD INJURY GCS 15 + PERITONITIS


    Sup. RUPTURE LIEN E.C ABDOMINAL BLUNT
    TRAUMA

    PLANNING EXAMINATION : Counting blood cell,


    X-Ray Skull AP/L View, USG Abdomen

    PLAN THERAPY

    O2 2-6 liter
    Intravenous Fluids
    Intravenous Antibiotics
    Intravenous Analgetic
    Catheter
    Consult to the general surgeon

    RADIOLOGICAL
    FINDING

    USG

    L/O/G/O

    Thank
    You
    BAGIAN ILMU BEDAH

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