IDENTITY

Name : Mr. MS
Age : 22 years old
Sex : Male
Address : Anduonohu
Admission : December, 21th 2017
Doctor in charge : dr. H. Syamsul Rijal, Sp. B
 HISTORY TAKING
 Main complain : Pain at lower left abdomen
 Anamnesis :

The patients come to hospital with pain at lower left abdomen since 2 hours ago after a
traffic accident
Mecanism of trauma :
There were no history of unconsciousness (-), nausea (-) and vomiting (-)
There were no history of bleeding nose (-), bleeding ear (-), and bleeding mouth (-)
There was previous medication (+)
There were no history of alcohol comsuption and drugs
 PRIMARY SURVEY
A
Clear

RR 20x/min regular, spontaneous B

thoracoabdominal type, symmetrical
C BP 110/80 mmHg
Pulse = 80x/min, regular, strong

D
GCS 15 (E4M6V5), pupil equal Ø 2,5mm/2,5mm, light reflex +/+

E T = 36.80 C (axillary)
 SECONDARY SURVEY
Head : Within Normal Limit
Face : Within Normal Limit
Eyes : Within Normal Limit
Nose : Within Normal Limit
Mouth : Within Normal Limit
Ears : Within Normal Limit
Neck : Within Normal Limit
Thoraks : Within Normal Limit
Stomach : Localized state
Upper/Low limb : Within Normal Limit
 LOCALIS STATE

Abdomen :
Inspection : flat, follow the motion breath, distended (-)
Auskultation : Peristaltic (+) within normal limit
Palpation : tenderness (+) at left lower abdomen, defans
muscular (-)
Perkusi : Tymphani (+)
 PLAN OF DIAGNOSTIC

 Complete Blood Count and Chemistry Blood Count

 USG Abdomen
Clinical Finding
 LABORATORY FINDINGS
 WBC
 HB

 PLT
 DIAGNOSIS

Abdominal Pain e.c Blunt Abdominal Trauma

 MANAGEMENT
Non Pharmacologycal Pharmacologycal

 Bed rest  IVFD

 Analgetics
 Consult general surgeon
 H2RA
 Thank You

BAGIAN ILMU
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