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Departement of SURGERY

IGD, 01th juny 2014

(19.00 pm- 07.00 am)

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Identity

Name : Ny. E

Age : 27 YO

Address : Lamongan

Date : 01 Juny 2014

RM :445332

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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. patientriding his motorcycle without a helmet. patients in themotorcycle 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 (-), chestpain (-), abdominal pain (-)

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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 mmHgRR 78x/minute, regular, Acral Warm and dry to touch

Red, CRT: < 2 seconds

Disability :GCS 456

Exposure : temp 36, Vulnus abrasio regio shoulder

right

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Secondary Survey :

KL :

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 -/-

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LOCALIZED STATUSRegio shoulder right

Look : hematom (-), odem (+), deformitas (-),

vulnus abrasio ukuran 2x2cm

Feel : Pain +, crepitation -, warm -,

Move : ROM limited by pain

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Assesment

Susp. Close fracture clavicula dextra

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PLANING DIAGNOSIS

DL CT-BT

X-ray photo thorax

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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

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X-ray photo thorax

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Secondary assesmentClose fracture clavicula dextra1/3 medial simple type

undisplace

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02 nasal 3lpm IVFD Assering 1500cc/24jam

Inj. Ketorolac 1 amp

Inj. Ranitidin 2x1 amp

Inj. Ceftriaxon 2g

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Subjective complaintVital sign

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Education

Explaine to the family about the disease of thefamily, about its theraphy and intervention will be

done, and also about complication and prognosis .

Take a planty of rest

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Thank you