MAS / M /19yo

Chief complaint: Pain on the epigastric region

It has been suffered by the patient since 15
hours before admission. Previously patient was
riding a motor cycle suddenly fell by himself and
hit a rock in the sidewalk onto his abdomen.
History of vomiting (-), unconsciousness (-),
seizure (-).
Primary Survey
A : clear
B : spontaneously, RR 24 x/i
C : warm acral, BP 120/70 mmHg, HR 96 x/i, Temp
36.4oC
D : GCS 15
E : log roll, undressed

VAS : 6
Secondary Survey
Head : No abnormality was found
Neck : No abnormality was found
Chest :
L : symmetric
L : Vesicular on the both side
F : resonance same on the both side, tactile fremitus same on the both side
Abdomen:
L : symmetric, excoriated wound on the epigastrium, distention (-)
L : Peristaltic (+) decreased
F : muscular rigidity (-), tenderness (+) on the epigastric region

Genital : Male, No abnormality was found

Extremities : No abnormality was found

DRE ; Perineum usual, Sphincter ani tight, pain on whole clockwise. Hand gloves feces (+),
Blood and mucous (-).
Laboratory findings:
Hb / Hct / WBC / PLT : 13.5 / 39.8 /20.76 /319
Na/K/Cl : 136/4.1/102
Ur/Cr : 30.80/1.13
Random Glucose Level : 115.90
Chest X-Ray
CT Scan Abdomen
Working Diagnose:
Blunt Abdominal Injury with hollow organ
perforation
Management:
- Fasting
- Insertion of NGT
- Insertion of urinary catheter came out clear yellow urine 200 cc
- IVFD Crystalloid
- Inj. Antibiotic
- Inj. Analgetic

Patient was prepared for Exploration Laparatomy