No. Name:Mr. IsSex:MaleAge:21 years oldNo. Reg:621696

Chief complaint :Abdominal painHistory taking:Suffered since 5 hours before admitted to the hospital due to traffic accident. Bloody urinate (+) since accident. Prior medical care at Maros hospitalMechanism of injury:He was riding the motorcycle, suddenly he fell down by himself and his body bumped to the groundInjury sustain:Right lower abdomenSymptom & sign:Pain, bloody urinateExamination:Physical examination, laboratory examination, USG abdominal, chest x-ray, pelvis x-ray

PHYSICAL EXAMINATION Primary SurveyA:ClearB:RR: 20 x/minutes, spontaneous, symmetric, thoraco abdominal type C:BP: 110/70 mmHg, HR : 64 x/minutes, regular, adequateD:GCS 15 (E4M6V5), pupil equal 2,5 / 2,5 mm , LR +/+E:T (ax) : 36,7oC

Secondary SurveyRight abdomen :I: Seen flat, follow breath moving, wound (-) , hematoma (+), skin colour same with vicinityA : Peristaltic (+) normal P : Tenderness (+) at the whole abdomen, defance (+)P : Tympani (+)Left lower flankI: Seen excoriated wound size 3x3 xm, edema (-), hematome (-)

Urologycal states

Costovertebra region :I : skin colour same with vicinity, allignment normal, gibbus (-) , edema (+), hematoma (+)P : Tenderness (+) at right region abdomenSuprapubic region :I : bulging (-), wound (-), skin colour same with vicinity,P : Tenderness (-)

Genitalia external region

Perianal region :I : Seen skin colour more darkness from vicinity, hematoma (-), udema (-) , wound (-)P : Tenderness (-)

Penis region :I : Seen circumed, OUE normal, hematoma (-), udema (-), meatal bleeding (-)P : Tenderness (-)

Digital Rectal ExaminationSphincter was tight Mucous was smoothAmpulla was empty, mass tumour (-)

Gloves : blood (-), feces (+), slime (-)

Laboratory ResultWBC:21,6 x 103 / LRBC:2,98 x 106 / LHGB:8,4 g/dLHCT:25,2 %PLT:284 x103/ LCT / BT:700 / 300Blood Sugar:96 mg/dlUreum:17 mg/dlCreatinin:0,8 mg/dlGOT / GPT:251/223 /L

UrinalisisColour:red lecosit sediment : fullpH:7,0 eritrosit sediment : fullBj:1,020 glucose:negative urobilinogen:Normalbilirubin:Negativeketon:+1/5nitrit:PositiveBlood:+5/250Lekosit:+3/500

Chest X-ray

Pelvis X-ray

Abdominal CT Scan

Abdominal USG

WORKING DIAGNOSIS :Generalized peritonitis e.c suspect intraabdominal bleeding due to suspect rupture of solid organMANAGEMENT: O2 IVFD Apply NGT Blood transfusion Medicaments Report to senior digestive surgeon, advice: immediately laparotomy exploration Report to senior urology surgeon, advice: explore retroperitoneal cavity

Operating ProcedurePatient was lying in supine position under GADisinfection and draping procedure Perform midline incision, deepen until peritoneum Open peritoneum, seen blood approximately 500ccIdentificated solid organ liver and lien seen goodIdentificated Hollow viscus organ from gaster to rectum , seen no perforationOpen white line identification Right KidneySeen completely shattered kidney (Right Kidney rupture Grade V)Fixate and ligation vasa renalis, continue with perform Right Nefrectomy KidneyLigation the ureter and cut it until distalBleeding controle and performe 1 drain at cavum retroperitonealClose wound layer by layer Operation finished

POST OP DIAGNOSIS

PROGNOSIS:

:Generalized peritonitis e.c retroperitoneal bleeding imbibition + rupture of kidney grade V

GoodFOLLOW UP:Vital sign

Campbell-Walss Urology: 9th ed. 2007Handbook of Urology; Diagnosis and Therapy 9th ed. 2007

Grading Renal Trauma (Campbell-Walss Urology: 9th ed. 2007)

Practical algorithm in the acute treatment of renal trauma(Genitourinary Trauma; Urology Clinic of North America, Elsevier Saunders 2006: p.17)

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