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 ResponseDate/hour

patient came to ER

Examination hour

Laboratory Examination

Radiology Examination

Hour of Diagnostics

Date/hour patient

out from ER

DPJP

Send Result Send Result

August 27th 201504.30

04.33 05.00 05.45 05.30 06.00 06.00 Dr.dr. Azharudd

in. Sp.OT.K.S

pine

Chief Complaint: Can’t move af the lower extremity

Present illness historyPatient came to Zainoel Abidin emergency room with a chief complaint Can’t 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 limitNeck in normal limitThorax in normal limitAbdomen 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 1111 1111

VAS : Moderate

Mild 1-3 Moderate 4-6 Severe 7-10

Non opioid + adjuvant- COX-2- Ibuprofen- Aspirin- Acetaminophen

Opioid + nonopioid + adjuvant-Codein-Propoxyphene-Hydrocodone-Tramadol

Opioid + nonopioid + adjuvant-Oxycodone-Morphine-Hydromorphone-Fentanyl

Assessment:1.Dislocation fracture vertebra lumbal 1-2 with

frankel B2.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 CM2.Blunt abdominal injury with stable

haemidinamic (ICD 10 CM3.Peritonitis ec susp perforasi hollow organ

(ICD 10 CM

Consult to orthopedic division:• Hospitalize• MRI Spine• Logg roll /2 hours• Posterior decompression + stabilization

electiveConsult to Digestive Surgery division:• Laparotomi Eksploration emergency

Follow up Date S O A P

26/8/2015 AD 1

Pain(+) at the abdominal region

General Condition : goodBP : 130/80 mmhgPulse : 80x/minuteRR : 20x/minuteL/S at the abdominal region :

•I : symetrically, distension (-), hematoma (+)

•A: bowel sound (+)•P: pain (+),defans muscular (+)•P: thympani (+), liver dullness (+)

Neurologic examination 5555 5555 1111 1111

1. Dislocation fracture of the VL1-2 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

O2 - 10 litre via face maskIVFD RL 20 drips/minNeck collar NGT decompresiUrine catheter Metyl prednisolone Drip. 2100 cc for 1 hoursCeftriaxone Inj. 1 gKetorolac Inj. 30 mgRanitidin Inj. 50 mg

Patien reffuse medical advise