SATURDAY

FEBRUARY 17, 2018

MR. M, 18 Y/O
ALANSAN JULIO SUTANTO
ON DUTY: dr. JONNY SETIAWAN, SP.B
 IDENTIT Y
 Name : Mr. M
 Age : 18 y/o
 Address : Tanah Merah
 Occupation : Student
 Admission : February 17, 2018 (05.00)
 Examination : February 17, 2018 (05.00)
 PRIMARY SURVEY

 Airway and cervical control: CLEAR

 Patient was conscious and able to talk
 Look: cyanosis (-), agitation (-)
 Listen: snoring (-), stridor (-), gurgling (-)
 Feel: blowing air (+)
 PRIMARY SURVEY

 Breathing and ventilation: CLEAR

 RR = 18 x/minutes
 O2 = 99%
 Use of accessory inspiratory muscle (-)
 Symmetrical chest expansion
 Percussion: resonant in both lung fields
 PRIMARY SURVEY

 Circulation: CLEAR
 Pulse rate: 80 x/minutes, strong, regular
 Blood pressure: 110/70 mmHg
 Source of external bleeding: there was a source of
external bleeding from an excoriated wound on the
left elbow
 Source of internal bleeding: -
 PRIMARY SURVEY

 Disability: CLEAR
 GCS E4M6V5
 Round pupil, 3mm/3mm, direct pupillary reflex +/+,
indirect pupillary reflex +/+
 Signs of lateralization (-)
 PRIMARY SURVEY

 Environment: CLEAR
 Body temperature 37.1 oC
 SECONDARY SURVEY: AMPLE
 Allergy : Fishes and prawns
 Medication : -
 Past Illness : No history of past illnesses
 Last Meal : Fried bananas and bread 6 hours before
admission
 Event : Trauma
 SECONDARY SURVEY: MIST
 Mechanism of Injury
Thirty minutes prior to admission patient was riding his
motorcycle when a bajaj accidentally hit him, losing his
balance, and fell on to the road with his head and chest
hitting the pavement. The patient claimed he was not
wearing helmet. The patient claimed there was no period
of losing consciousness, but he felt dizzy and pain on his
head, right shoulder & chest, and left arm. The patient also
claimed of having difficulty in moving his both arms.
Nausea, vomiting, and seizure were denied by the patient.
 SECONDARY SURVEY: MIST

 Injury sustained
 Bump on the right parietal side of the head, size 4.1 x
3.9 cm, bleeding (-), pain (+), hard consistency,
distinct border
 Excoriated wound on the left elbow, size 3.2 x 2.1 cm,
active bleeding (+), pain (+), distinct border, dermis
as the base of the wound
 SECONDARY SURVEY: MIST

 Sign and symptoms

 Active bleeding and pain from the excoriated wound
on the left elbow
 Pain from the bump on his head
 Pain from his right shoulder and chest
 SECONDARY SURVEY: MIST
 Treatment and trend in vital sign
Wound toilet
BP: 110/70 mmHg
HR: 80 x/minutes
RR: 18 x/minutes
T: 37°C
 HISTORY OF IMMUNIZATION
 Patient denied history of TT immunization within the last 10
years.
 HEAD-TO-TOE EXAMINATION
 Head: normocephaly, bump (+), bleeding (-)
 Eye : round pupils, 3/3 mm, direct LR +/+, indirect LR +/+
 Nose : deformities (-), septum deviation ( -), discharge (-)
 Ear : deformity (-), discharge
 Mouth : within normal limits
 HEAD-TO-TOE EXAMINATION
 Thorax
 Inspection : symmetrical chest expansion, pain on the
right chest in inspiration (+), deformity (-), use of
accessory inspiratory muscle (-), hematoma (-),
lacerations (-)
 Palpation: symmetrical chest expansion, tenderness on
the right chest (+), crepitation (-)
 Percussion: resonant +/+, cardiomegaly (-)
 Auscultation : vesicular +/+, ronchi -/-, wheezing -/-,
regular 1 st and 2 nd heart sound, murmur (-), gallop (-)
 HEAD-TO-TOE EXAMINATION

Abdomen
 Inspection : appear flat, hematoma (-), lacerations (-)
 Auscultation : bowel sounds (+) 6 x/minutes
 Palpation : supple, tenderness (-)
 Percussion : tympanic in all abdominal regions
 HEAD-TO-TOE EXAMINATION
Extremities
Warm extremities, CRT < 2 secs
 Upper extremities: excoriated wound on the left elbow (+),
pain (+)
 Upper arm
 Look: deformity (-), edema (-), hyperemia (-)
 Feel: normal sensibility
 Move: limited ROM of the right upper arm (60 degrees)
 Lower extremities: edema (-), hyperemia (-), pain (-)
Motoric: 5/5/5/5
 LOCALIZED STATUS

 Bump on the right parietal side of the head, size 4.1 x

3.9 cm, bleeding (-), pain (+), hematoma (-), hard
consistency, distinct border
 LOCALIZED STATUS

 Excoriated wound on the left elbow, size 3.2 x 2.1 cm,

active bleeding (+), pain (+), distinct border, dermis as
the base of the wound
 RESUME
Mr. M, 18 y/o, came to the Atma Jaya Hospital with chest and
shoulder pain af ter traf fic accident. The patient was dizzy and he had
dif ficulty in moving his both arms. On physical examination was found
a bump on the right parietal side of the head, and excoriation wound
on the lef t elbow. Pain was found on inspiration and thorax palpation.
There was a limited ROM on the upper right arm (60 degrees)
Localized status:
 Bump on the right parietal side of the head, size 4.1 x 3.9 cm,
bleeding (-), pain (+), hard consistency, distinct border
 Excoriated wound on the left elbow, size 3.2 x 2.1 cm, active bleeding
(+), pain (+), distinct border, dermis as the base of the wound
 INITIAL DIAGNOSIS
 Mild traumatic brain injury
 Right chest & shoulder pain e.c. suspected right costae
fracture and shoulder dislocation
 Excoriated wound on the left elbow
 WORK UP CONSIDERATION
ER Co-ass
 CT Scan non-contrast  CT Scan non-contrast
 Cervical x-ray  Cervical x-ray
 Right shoulder x-ray  Right shoulder x-ray
 Chest x-ray  Chest x-ray
CT SCAN (NON CONTRAST)
CERVICAL X-RAY
RIGHT SHOULDER X-RAY
CHEST X-RAY
 DIAGNOSIS
 Mild traumatic brain injury
 Blunt trauma a/r thorax dextra
 Excoriated wound on the left elbow
 TREATMENT

ER Leader Doctor Co-ass

 IVFD: RL 500cc  IVFD: RL  IVFD: RL
 Paracetamol 1g IV 1500cc/24h (+ 1500cc/24h (+
Tramadol Tramadol
50mg/kolf) 50mg/kolf)
 Paracetamol 1g IV  Paracetamol 1g IV
 Sling
 Wound toilet
 Wound dressing
with gauze sponge
and fixomull stretch
THANK YOU