Departement of SURGERY

IGD, 01th juny 2014

(19.00 pm- 07.00 am)

Identity
Name : Ny. E
Age : 27 YO
Address : Lamongan
Date : 01 Juny 2014
RM :445332



Anamnesis
Chief complaint:
Pain in the shoulder right
Present illnes:
Patient came with Pain in the shoulder right since
30 minute post traffic accidents complains. patient
riding his motorcycle without a helmet. patients in the
motorcycle was hit by other motor cycle from the
behind direction, patient fell off the motorcycle to the
right side. there is no clash in the head. Headache (-)
Nausea (-), vomit (-), fainting (-) , PTA (-), chest
pain (-), abdominal pain (-)
PRIMARY SURVEY
Airway :
Clear -, snoring-, gurgling-, potensial obstruction (-)
Breathing : spontan, simetric, retraction-, ves/ves, rh-
/-, whz-/- RR : 21x/minute, SPO2= 99%
Circuration and bleeding control :BP 120/85 mmHg
RR 78x/minute, regular, Acral Warm and dry to touch
Red, CRT: < 2 seconds
Disability :GCS 456
Exposure : temp 36, Vulnus abrasio regio shoulder
right


Secondary Survey :
K L :
anemis -/-, icterik -/-, cyanosis -/-, dysp , vulnus abrasio regio shoulder
rigt 2x2
Thoraks :
I : simetric , retraction (-), lesion (-)
P : simetric, fremitus (-)
P : sonor/sonor
A : pulmo : simetris (+), ves /ves, rh -/-, wh -/-
cor : S1S2 single, murmur (-), gallop (-)

Abdomen :
I : flat, distended (-), lesion (-)
A : bowel sound (+)
P : soepel, Pain (-)
P : tympani (+), liver and spleen were not palpable,
- extremities : acral warm, dry, red, edema -/-






LOCALIZED STATUS
Regio shoulder right
Look : hematom (-), odem (+), deformitas (-),
vulnus abrasio ukuran 2x2cm
Feel : Pain +, crepitation -, warm -,
Move : ROM limited by pain




Assesment
Susp. Close fracture clavicula dextra
PLANING DIAGNOSIS
DL
CT-BT
X-ray photo thorax

Laboratory Findings
Diff count: 1/1/82/12/4
Hematocrite: 42,5%
Hb 13,1 mg/dl
Leukocytes : 12000
Thrombocyte : 268.000
Bleeeding Time : 130
Clothing time : 830
GDA 116


X-ray photo thorax
Secondary assesment
Close fracture clavicula dextra1/3 medial simple type
undisplace

02 nasal 3lpm
IVFD Assering 1500cc/24jam
Inj. Ketorolac 1 amp
Inj. Ranitidin 2x1 amp
Inj. Ceftriaxon 2g
Subjective complaint
Vital sign
Education
Explaine to the family about the disease of the
family, about its theraphy and intervention will be
done, and also about complication and prognosis .

Take a planty of rest

Thank you