September 30th 2014

Name : A.B
Age : 42 years old
Sex : Male
Address : Fatululi



Cheif Compain:
Pain in the left shoulder since this morning
MOI :
Pasient was reffered from Soe Hospital with
diagnosis fractur os clavicula sinistra. Pasien
had an accident this morning . The car they
rode was inverted and he thrown out of the
front window. His head and shoulder hit the
road. Pain in his shoulder (+), swelling, and
hard to be moved. There were wound in his
backhead. His eyes were swelling.
History of blood came from his left ear and
nose (+)
Unconsciousness (-), nausea (-), vomit 1x
when arrived at Johannes Hospital the
content was food and water. Blood (-)
approximately 100 cc.

A : clear, patent
B : RR 25 x/m, spontan,
C : BP 120/90 mmHg Pulse 94 x/m,
D : voice
GCS : E3V5M6
Head : 1 VE (+) regio occipital 3 x 3 cm, bottom
of the wound is skin, active bleeding (-)
hematom (-)
Eye : anemic (-/-), light reflex (+/+), icteric (-),
racoon eyes +/+
Ear : clot(+/-)
Nose : clot (+/+)
Neck : enlargement (-)
Left Shoulder : deformity (+), swelling (+),
crepitation (+), tenderness (+)



Pulmo :vesicular (+/+), ronchie (-/-), wheezing
(-/-)
Cor : S
1/2
single, murmur (-/-), gallop (-/-)
Inspection : mass (-), scar (-), wound (-)
Auscultation : peristaltics normal
Palpation : tenderness pain (-) , mass (-)
Percusion : timpany sound (+)


Look
normal
Feel
normal
Move
normal


WBC : 12,63 x 10
3
/uL
RBC : 4,99 x 10
6
/uL
HGB : 14,3 g/dL
PLT :260 x 10
3
/uL
Mild head injury
Susp. Basillar skull fracture
Closed fracture 1/3 middle clavicula sinistra
VE et regio occipital

Head up 30 o
IVFD RL 20 tpm
Ketorolac 3 x1 amp IV
Ranitidin 2 x 1 amp. IV
Ceftriaxon 2 x 1 amp IV
Bandage
Head CT scan