12 Juli 2013 21.00 06.

00 WITA

Identity
Name Age Sex Job Address

:Mr. HJK :18 y.o :Male :Driver :Osmok-Alak

Anamnesis
Chief Complaint:

Unconsiousness post trauma Present History:

The patient is taken to ER complained unconsiousness 30 minutes. The patient was crushed by car then falling from motorcycle and his body hit the road. Bleeding of ear and nose (+). History of alcohol consumption(+) a hour before the crush.

Primary Survey
A
B

: Clear : RR 36x/m, abdominothorakal.

C D

Therapy: O2 4 liter/m Therapy : Fluid resusitation loading RL 1000cc, maintanance 20tpm, catheter

: BP 100/60 mmHg, pulse 126 x/m, reguler.

: E2V3M6, rhinorhea (+/+), ottorhea (-/+).

 E:
Laceration at pelvis regio, sized 18 x 15 cms, floor: muscle, margin :

skin, fat, & fascia. Structure found : testis sinistra, vas deferens sinistra, epididimis sinistra, pulse beat of a. femoralis, bleeding minimal, irreguler, dirty (soul, grass). Laceration at regio femoralis anterior dextra, sized 20 x 10 cm floor: muscle, margin : skin , fat, and fascia, minimal bleeding, irreguler, dirty (soul, grass). Deformity of hip joint, limited pasif room, pain (+).

Secondary Survey
GCS

: E2V3M6 Vital sign : BP 110/70 mmHg, Pulse 98 x/mnt, RR 24 x/mnt Eyes : anemic (-/-), light reflex (+/+), icteric (-/-) Ear : ottorhea (-|+) Nose : rhinorhea (+|+) Throat : Normal

Chest
Inspection : chest expansion simetric (+/+), reguler, abdominothoracal Palpation : vocal fremitus simteric (R=D)
Percusion : sonor (+/+)

Auscultation : vesicular (+/+), ronchi (-/-),

wheezing(-/-)

Abdominal
Inspection : distended (-)
Auscultation : peristaltics is normal Palpation : mass (-), tenderness (-)

Percusion : tympani sound

Hip
Inspection : deformity of hip joint dextra, limited pasif

room, redness (-).

Palpation : tenderness (+), imobilized, crepitation (-).

Extremities
Inspection

: Laceration at regio femoralis anterior dextra, 20 x 10 cms floor: muscle, margin : skin, fat, & fascia, minimal bleeding, irreguler, dirty (soul, grass).

Palpations : tenderness (+), warm (-)

Assesment
Unconsiousness ec moderate head injury DD/ alcohol

intoxication Suspect base skull fracture Multiple laceration wound Suspect hip joint dislocation

Planning diagnostic
CBC
CT scan head Xray hip joint AP & lateral

Therapy
IVFD RL 1000cc, maintanace 20 dpm
Wound toilet, hecting and dressing Ceftriaxon 1 X 1 gr/IV (sk)

Ketorolac inj. 30 mg/IV

Piracetam 4X3 gr/IV Ranitidin 2 X 25 mg/IV Internal/external drainase if ICB

THANKS