Tegar Arya Ringga, L, 31 tahun, 00300426
Primary Survey:
A: bicara jelas, snorring (-), gurgling (-) -> clear
B: RR 26 x/mnt, SpO2 99% on room air, simetris
(+), KG (-), (sonor/sonor), vesikuler (+/+) --> clear
C: Akral hangat (+), TD 110/51 mmhg, HR 103 x/me
nit, CRT <2 dtk --> clear
D: GCS E4V5M6, pupil isokor 3mm/3mm, lateralisa
si (-)
Initial assessment: no potential life threatening
Secondary Survey:
A: tidak ada
M: nebulizer
P: asma bronkial
L: pukul 23.00
E: post KLL
Kel.utama:
Post KLL
RPS:
4 jam SMRS (06.00) pasien sedang mengendarai m
otor lalu menabrak truk yang ada di depannya. Pasi in front of him. The patient wore a helmet. History
en mengenakan helm. Riwayat pingsal , mual, mun
tah disangkal. Pasien ingat kejadian. Riwayat bentu
ran di bagian tubuh lain ada di perut, tangan kiri da
n kaki kanan. Pasien lalu dibawa ke RS PKU Muham
madiyah Yogyakarta dan dilakukan pemeriksaan la
b dan radiologi. Pasien sempat mengalami syok da
n dilakukan resusitasi 3 l kristaloid, 500 cc koloid da into shock and was resuscitated with 3 liters of crys
n 1 kolf PRC. Pasien lalu dirujuk ke RSS untuk mend
apat penanganan lebih lanjut.
Tegar Arya Ringga, M, 31 years old, 00300426
Primary Survey:
A: speak clearly, snorring (-), gurgling (-) -> clear
B: RR 26 x/min, SpO2 99% on room air, symmetrica
l (+), KG (-), (sonor/sonor), vesicular (+/+) --> clear
C: Acral warm (+), BP 110/51 mmHg, HR 103 x/min,
CRT <2 sec --> clear
D: GCS E4V5M6, pupil isocor 3mm/3mm, lateraliza
tion (-)
Initial assessment: no potential life threatening
Secondary Survey:
A: none
M: nebulizer
P: bronchial asthma
L: 23.00
E: post traffic accident
Chief complaint:
Post traffic accident
Recent Medical History:
4 hours before admitted to the hospital (06.00) the
patient was riding a motorbike and then hit a truck
of fainting, nausea, vomiting was denied. The patie
nt remembers the incident. History of impact on ot
her body parts in the abdomen, left hand and right
leg. The patient was then taken to PKU Muhamma
diyah Yogyakarta Hospital and performed laborato
ry and radiological examinations. The patient went
talloid, 500 cc of colloid and 1 kolf of PRC. Then the
patient was referred to RSS for further treatment.
Past Medical History:
 History of Allergies (-) , DM (-), HT (-), Heart disease
RPD: (-), asthma (+)
Riwayat Alergi (-) , DM (=), HT(-) Peny. Jantung (-), Physical examination
asma (+) KU Medium, E4V5M6
Pemeriksaan Fisik BP: 110/51 mmHg
KU Sedang, E4V5M6 N: 103 x/min
TD: 110/51 mmHg RR: 26 x/min
N: 103 x/mnt SpO2 99% on Room air
RR: 26 x/mnt S: 36.5°C
SpO2 99% on Room air Head:
S: 36,5°C Pupil isocor 3mm/3mm, CA (-/-), SI (-/-), cornea refl
Kepala: ex (+/+), light reflex (+/+)
Pupil isokor 3mm/3mm, CA (-/-), SI (-/-), RC (+/+), R Upper face
K (+/+) I : symmetrical, VE (+) frontal region, VL (+) frontal
Upper face region 5x2cm in size with bone base, hematoma
I : simetris, VE (+) regio frontal,VL (+) regio frontal (-), swelling (-), active bleeding (-)
uk. 5x2cm dengan dasar tulang, hematoma (-), swe P: sensory in normal limit, tenderness (-), crepitus
lling (-), bleeding aktif (-) (+) frontal bone
P: sensoris dbn, NT (-), krepitasi (-) Middle face
I : symmetrical, racoon eye (-/-), hematoma (-), tele
Middle face canthus (-), diplopia (-), eye movement in normal li
I : simetris , racoon eye (-/-), hematoma (-), telekan mit, edema (-), rhinorrhea (-) , bloody otorrhea (-),
tus (-), diplopia (-), gerakan bola mata dbn, edema battle sign (-), nasal septal deviation (-), step off (-),
(-), rhinorrhea (-) , bloody otorrhea (-), battle sign VE (+) nasal and left periorbita, VL (+) 1x1cm left pe
(-), deviasi septum nasi (-), step off (-), VE (+) nasal riorbita region at the base of the cutis
dan periorbita sinistra, VL (+) 1x1cm regio periorbit P : sensory in normal limit, floating maxilla (-), tend
a sinistra dasar kutis erness (-), crepitus (-)
P : sensoris dbn, floating maxilla (-), NT (-), krepitasi Lower face
(-) I : symmetrical, dental avulsion (-) VE (+) perioral, l
Lower face abium, chin, VL(-), edema (-), deformity (-) maloccl
I : simetris, avulsi dental (-) VE (+) perioral, labium, usion (-), hematoma (-)
dagu, VL(-), edema (-), deformitas (-) maloklusi (-), P : sensory dbn, tenderness (+), gliding mandible
hematoma (-) (-), crepitus (-)
P : sensoris dbn, NT (-), gliding mandibula (-), krepit Neck:
asi (-) Lesion (-), JVP does not increase, tenderness (-)
Leher: Thorax:
Jejas (-), JVP tidak meningkat, NT (-) I: lesion (-), symmetrical (+), lagging motion (-/-)
Thorax: P: VF ka=ki
I: Jejas (-), simetris (+), ketinggalan gerak (-/-) P: sonor/sonor
P: VF ka=ki A: Vesicular (+ /+), wheezing (+/+), rhonchi (-/-)
P: sonor/sonor Abdomen:
A: Vesikuler (+ /+), wheezing (+/+), ronkhi (-/-) I: Distension (-), VE (+)
Abdomen: A: BU (+) is normal
I: Distensi (+), VE (+) P: supel (+), defans (-), tenderness (-)
A: BU (+) normal P: tympanic (+)
P: Supel, defans (-), NT (-) Pelvis:
P: timpani (+)   L : Wound (-) deformity (-) swelling (sde) terpasan
Pelvis: g pelvic wrap.
L : Wound (-) deformity (-) swelling (sde) terpasan F : NT (+) regio hemipelvic dextra, NVD (-)
g pelvic wrap. M : limited due to pain
F : NT (+) regio hemipelvic dextra, NVD (-) Extremities:
M : limited due to pain Acral warm (+), strong pulse, CRT <2 seconds, VE m
Extremities: ultiple extremities bilateral superior and inferior bil
Acral warm (+), strong pulse, CRT <2 seconds, VE m ateral, deformity (+), swelling (+)
ultiple extremities bilateral superior and inferior bil Localist status of left humerus :
ateral, deformity (+), swelling (+) L : wound (-), swelling (+) at middle third humerus,
Localist status of left humerus : deformity (+) varus angulation
L : wound (-), swelling (+) at middle third humerus, F : tenderness (+), NVD (-)
deformity (+) varus angulation M : Limited due to pain
F : tenderness (+), NVD (-) Localist status of left antebrachii :
M : Limited due to pain L : Wound (-), deformity (+) varus angulation. swelli
Localist status of left antebrachii : ng (+) at middle antebrachii.
L : Wound (-), deformity (+) varus angulation. swelli F : tenderness (+), NVD (-)
ng (+) at middle antebrachii. M : limited due to pain
F : tenderness (+), NVD (-)
M : limited due to pain Localist status of right cruris:
L : swelling (+) at middle third cruris, deformity (+)
Localist status of right cruris: shortening, wound (-)
L : swelling (+) at middle third cruris, deformity (+) F : NT (+), NVD (-)
shortening, wound (-) M : limited due to pain
F : NT (+), NVD (-) Saturation of left upper extremity
M : limited due to pain Digiti 1: 99%
Saturation of left upper extremity Digiti 2 : 99%
Digiti 1: 99% Digiti 3 : 99%
Digiti 2 : 99% Digiti 4 : 99%
Digiti 3 : 99% Digiti 5 : 99%
Digiti 4 : 99% Vascular status of left upper extremity:
Digiti 5 : 99% a. Axillaris (+)
Vascular status of left upper extremity: a. Brachialis (+)
a. Axillaris (+) a. Radialis (+)
a. Brachialis (+) a. Ulnaris (+)
a. Radialis (+)
a. Ulnaris (+) Hasil Lab Tegar Arya 1/10/21 10.00
AL 21.34
Hasil Lab Tegar Arya 1/10/21 10.00 AE 3.43
AL 21.34 Hb 9.8
AE 3.43 Hmt 29.1
Hb 9.8 AT 149
Hmt 29.1 PPT 17.8 (14.8)
AT 149 APTT 28.7 (31.2)
PPT 17.8 (14.8) INR 1.24
APTT 28.7 (31.2) HbsAg NR
INR 1.24 Alb 2.68
HbsAg NR SGOT 249
Alb 2.68 SGPT 201
SGOT 249 BUN 10.1
SGPT 201 Cr 1.74
BUN 10.1 LDH 617
Cr 1.74 CRP 9
LDH 617 GDS 143
CRP 9 Na 141
GDS 143 K 3.93
Na 141 Cl 108
K 3.93
Cl 108 Hasil AGD Tegar 1/10/21 10.00
 pH 7.282
Hasil AGD Tegar 1/10/21 10.00 PCO2 52.7
pH 7.282 PO2 180
PCO2 52.7 HCO3 25
PO2 180 BE -2
HCO3 25 SO2 99%
BE -2 Lac 4.71
SO2 99%
Lac 4.71 Hasil Lab Tegar Arya 1/10/21 16.35
AL 22.58
Hasil Lab Tegar Arya 1/10/21 16.35 AE 4.56
AL 22.58 Hb 12.7
AE 4.56 Hmt 38
Hb 12.7 AT 162
Hmt 38
AT 162 Hasil AGD Tegar 1/10/21 16.35
pH 7.260
Hasil AGD Tegar 1/10/21 16.35 PCO2 50.1
pH 7.260 PO2 183
PCO2 50.1 HCO3 22.7
PO2 183 BE -5
HCO3 22.7 SO2 99%
BE -5 Lac 6.34
SO2 99%
Lac 6.34 Non-Contrast 3D Head MSCT Expertise Results 1/1
0/21
Hasil Expertise MSCT Kepala 3D Non Kontras 1/10 Impression:
/21 - Soft tissue swelling with soft tissue defect in the fr
Kesan : ontal region
- Soft tissue swelling disertai soft tissue defect di re - Left frontal hemosinus and bilateral ethmoidal
gio frontalis - Depressed fracture of the left frontal bone, poor
- Hemosinus frontalis sinistra dan ethmoidalis bilat apposition and alignment
eral - Complete fracture of the left ethmoidal sinus, ade
- Depressed fracture os frontalis sinistra, aposisi da quate apposition and alignment
n aligntment kurang - Complete fracture of nasal os, adequate appositio
- Fracture completa sinus ethmoidalis sinistra, apos n and alignment
isi dan alignment cukup - No signs of EDH, SDH, SAH, ICH, IVH or cerebral e
- Fracture completa os nasal, aposisi dan alignment dema on the current MSCT Head photo
cukup
- Tak tampak tanda-tanda EDH, SDH, SAH, ICH, IVH
maupun oedema cerebri pada foto Head MSCT saa MSCT Abdomen Expertise Results with Contrast 1
t ini /10/21
Hasil Expertise MSCT Abdomen dengan Kontras 1/ Impression:
10/21 Hemoperitoneum in the hepatorenal space
Kesan : Right haematothorax with pulmonary contusion in
- Hemoperitoneum di hepatorenal space the posterobasal segment of the right inferior pul
- Hematothorax dextra dengan contusio pulmonu monary lobe
m di segmen posterobasal lobus inferior pulmo dex - No abnormalities were seen in the liver, spleen, v
tra esica fellea, pancreas, ren dextra et sinistra, bladde
- Tak tampak kelainan pada hepar, lien, vesica felle r, prostate and rectum. There are no visible lacerati
a, pancreas, ren dextra et sinistra, vesica urinaria, p ons or hematomas in these organs
rostat maupun rectum. Tak tampak gambaran laser - Intact visualized bone system
asi maupun hematoma pada organ-organ tersebut - Intra-VU balloon catheter inserted
- Sistema tulang yang tervisualisasi intak
- Terpasang balon catheter intra VU Abdomen Ultrasound Expertise Results 1/10/21
Hasil Expertise USG Abdomen 1/10/21 Impression:
Kesan : - Free intra-abdominal fluid (hepatorenal and periv
- Cairan bebas intraabdomen ( hepatorenal dan per esica space)
ivesica space) - No visible lacerations of internal organs
- Tak tampak laserasi organ dalam - No abnormalities were seen in the liver, vesica fel
- Tak tampak kelainan pada hepar, vesica fellea, lie lea, spleen, pancreas, both kidneys, bladder and pr
n, pancreas, kedua ren, vesica urinaria maupun pro ostate.
stat. - No paraaortic lymphadenopathy was seen.
- Tak tampak limfadenopati paraaortici. - Attached Balloon Catheter on Vesica Urinaria
- Terpasang Balon Catheter pada Vesica Urinaria Ro Cervical Expertise Results 1/10/21
Hasil Expertise Ro Cervical 1/10/21 Impression:
Kesan : - Cervical Interspinalis Spasm
- Spasme M.Interspinalis Cervicalis - No visible fracture, listhesis and dislocation of the
- Tak tampak fraktur,listhesis dan dislokasi pada ve cervical vertebrae
rtebrae cervicalis Results of Expertise Ro Lumbosacral 1/10/21
Hasil Expertise Ro Lumbosacral 1/10/21
Kesan :
- Diastasis sacroilliaca joint
- Tak tampak fraktur, listhesis, dan kompresi pada
vertebra lumbosacral
Hasil Expertise Ro Humerus 1/10/21
Kesan :
- Fraktur complete diafisis os humerus sinistra pars
tertia media,aposisi dan alignment buruk
Hasil Expertise Ro Antebrachii 1/10/21
Kesan :
- Fraktur completa diafisis os radius ulna sinistra pa
rs tertia mediodistal disertai dislokasi radioulna joi
nt distal sinistra,aposisi dan alignment kurang
Hasil Expertise Ro Thorax 1/10/21
Kesan :
- Pulmo tak tampak kelainan
- Besar cor normal
- Tak tampak fraktur pada sistema tulang yang terv
isualisasi
- Tak tampak tanda-tanda hidropneumothoraks pa
da foto thoraks saat ini
Hasil Expertise Ro Pelvis 1/10/21
Kesan :
- Diastasis simfisis pubis dan sacroilliaca joint
- Tak tampak fraktur dan dislokasi pada foto pelvis
- Tampak sisa kontras pada proyeksi vesica urinaria
Hasil Expertise Ro Femur 1/10/21
Kesan :
-Tak tampak fraktur maupun dislokasi pada femur
dextra
Impression:
- Sacroiliac joint diastasis
- No fracture, listhesis, and compression of the lum
bosacral vertebrae are seen
Ro Humerus Expertise Results 1/10/21
Impression:
- Complete fracture of the left humerus, pars tertia
media, poor apposition and alignment
Ro Antebrachii Expertise Results 1/10/21
Impression:
- Complete fracture of the diaphysis of the radius u
lna left pars tertia mediodistal with dislocation of t
he left distal radioulna joint, poor apposition and al
ignment
Ro Thorax Expertise Results 1/10/21
Impression:
- Pulmo does not appear abnormal
- Normal cast size
- No visible fracture in the visualized bone system
- There are no signs of hydropneumothorax on the
chest X-ray at this time
Ro Pelvis Expertise Results 1/10/21
Impression:
- Diastasis of the symphysis pubis and sacroiliac joi
nt
- No fractures and dislocations seen on pelvic radio
graphs
- Visible residual contrast on the projection of the
bladder
Ro Femur Expertise Results 1/10/21
Impression:
-No fracture or dislocation of the right femur is see
n
Ro Genue Expertise Results 1/10/21
Hasil Expertise Ro Genue 1/10/21
Kesan :
- Fraktur communitive diafisis os fibula dextra pars
tertia proksimal, aposisi dan alignment buruk
- Fraktur segmental diafisis os tibia dextra pars terti - Fracture segmental diaphysis os tibia dextra pars
a media, aposisi dan alignment buruk
- Tak tampak dislokasi pada genu
Hasil Expertise Ro Cruris 1/10/21
Kesan :
- Fraktur communitive diafisis os fibula dextra pars
tertia proksimal, aposisi dan alignment buruk
- Fraktur segmental diafisis os tibia dextra pars terti - Fracture segmental diaphysis os tibia dextra pars
a media, aposisi dan alignment buruk
Diagnosis
- Open depressed fracture of the left frontal bone
- Multiple excoriated wound of facial bone
- Lacerated wound of frontal region
- Lacerated wound of left foot
- Fracture of the nasal bone
- Bilateral lungs contusion
- Internal bleeding with stable haemodynamics
- Hematuria due to bladder contusion
- Close fracture of middle third of the left humerus
- Close fracture of distal third of the left radius ulna
with DRUJ injury
- Close pelvic ring injury APC type II
- Close segmental fracture of the right tibia
- Close fracture of proximal third of the right fibula
Neurosurgery:
Planned to debridement, depressed fracture correc tion (Refused procedure)
tion (Refused procedure)
Impression:
- Fracture of the communitive diaphysis of the fibul
a dextra pars tertia proximal, poor apposition and
alignment
tertia media, poor apposition and alignment
- No dislocation seen on genu
Ro Cruris Expertise Results 1/10/21
Impression:
- Fracture of the communitive diaphysis of the fibul
a dextra pars tertia proximal, poor apposition and
alignment
tertia media, poor apposition and alignment
Diagnosis
- Open depressed fracture of the left frontal bone
- Multiple excoriated wound of facial bone
- Lacerated wound of frontal region
- Lacerated wound of left foot
- Fracture of the nasal bone
- Bilateral lungs contusion
- Internal bleeding with stable haemodynamics
- Hematuria due to bladder contusion
- Close fracture of middle third of the left humerus
- Close fracture of distal third of the left radius ulna
with DRUJ injury
- Close pelvic ring injury APC type II
- Close segmental fracture of the right tibia
- Close fracture of proximal third of the right fibula
Neurosurgery:
Planned to debridement, depressed fracture correc
Plastic Surgery:
Plastic Surgery: - Wound toilet
- Wound toilet - Primary suturing
- Primary suturing - Close reduction
- Close reduction BTKV:
BTKV: Conservative
Conservative Digest:
Digest: Conservative
Conservative Urology:
Urology: Conservative
Conservative Ortho:
Ortho: - Immobilization with U-slab
- Immobilization with U-slab - Immobilization with Sugar tong splint
- Immobilization with Sugar tong splint - Immobilization with pelvic wrap
- Immobilization with pelvic wrap - Immobilization with long leg posterior splint
- Immobilization with long leg posterior splint - Planned to ORIF
- Planned to ORIF

Bagus santosa, M, 23 yrs, 1988175

Bagus santosa, L, 23 th, 1988175
KU :
Mulut tidak bisa di tutup
RPS :
2jam SMRS pasien mengeluh tidak bisa menutup m patient complained of not being able to close his
ulut setelah menguap lebar pasien sudah memerik
sakan diri ke klinik dan di lakukan usaha reposisi ol
eh klinik tetapi tidak berhasil. Dari klinik di saranka
n untuk ke RSS untuk penangan lebih lanjut.
Pasien memiliki riwayat serupa tetapi bisa kembali
lagi.
Chief complaint :
Mouth can't be closed
Recent Medical History :
2 hours of before admitted to the hospital, the
mouth after yawning widely. The patient had
checked himself into the clinic and tried to
reposition it by the clinic but to no avail. From the
clinic it is recommended to go to RSS for further
treatment.
The patient has a similar history but can come back
again.
RPD: RPD:
HT (-), DM (-), Peny. Jantung (-), Alergi (-) HT (-), DM (-), Pen. Heart (-), Allergies (-)

Pemeriksaan Fisik: Physical examination:

KU : Sedang, E4V5M6 KU : Medium, E4V5M6
TD: 120/80 mmHg BP: 120/80 mmHg
N: 88x/menit N: 88x/minute
RR: 20 x/menit RR: 20 x/minute
T: 36°C T: 36°C
SpO2: 100% on room air SpO2: 100% on room air
Kepala: Head:
CA (+/+), SI (-/-) CA(+/+), SI(-/-)
Upper face Upper face
I : simetris, VE (-) , VL (-), hematoma (-), swelling I : symmetrical, VE (-) , VL (-), hematoma (-),
(-), bleeding aktif (-) swelling (-), active bleeding (-)
P: sensoris dbn, NT (-), krepitasi (-) P: sensory dbn, NT (-), crepitus (-)
Middle face middle face
I : simetris , racoon eye (-/-), hematoma (-), telekan I : symmetrical, racoon eye (-/-), hematoma (-),
tus (-), diplopia (-), gerakan bola mata dbn, edema telecanthus (-), diplopia (-), eye movement dbn,
(-), rhinorrhea (-) , bloody otorrhea (-), battle sign edema (-), rhinorrhea (-) , bloody otorrhea (-),
(-), deviasi septum nasi (-), step off (-), VE (-) , VL (-) battle sign (-), nasal septal deviation (-), step off (-),
P : sensoris dbn, floating maxilla (-), NT (-), krepitasi VE (-) , VL (-)
(-) P : sensory dbn, floating maxilla (-), NT (-), crepitus
Lower face (-)
I : asimetris, avulsi dental (-) VE (-), VL(-), edema (-), lower face
deformitas (+) pada mandibular joint sinistra, malo I : asymmetry, dental avulsion (-) VE (-), VL(-),
klusi (SDN), hematoma (-) edema (-), deformity (+) in the left mandibular
P : sensoris dbn, NT (-),  (-), krepitasi (-), kesan dislo joint, malocclusion (SDN), hematoma (-)
kasi mandibular joint sinistra P : sensory dbn, NT (-), (-), crepitus (-), left
Leher: mandibular joint dislocation impression
Limfonodi (-/-), peningkatan JVP (-) Neck:
Thorax: Lymph nodes (-/-), increased JVP (-)
I: Simetris (+), ketinggalan gerak (-/-), jejas (-) Thorax:
P: VF ka=ki, krepitasi (-) I: Symmetrical (+), lagging motion (-/-), injury (-)
P: sonor/sonor P: VF ka=ki, crepitus (-)
A: Vesikuler (+/+), Rh (-/-), Wh (-/-) P: sonor/sonor
Abdomen: A: Vesicular (+/+), Rh (-/-), Wh (-/-)
I: Distensi (-) Abdomen:
A: BU (+) normal I: Distension (-)
P: NT (-), defans (-) A: BU (+) is normal
P: tympani (+) P: NT (-), defans (-)
Ekstremitas P: tympanic (+)
Akral hangat, CRT < 2 detik, edema (-), tremor (-)  Extremities
Warm acral, CRT < 2 seconds, edema (-), tremor (-)
Assessment:
Dislocation of temporomandibular joint Assessments:
Dislocation of temporomandibular joint
Plan:
Close reduction Plan:
Close reduction

Bernadus Rasendria Daniswara, L, 18 th, 0198819

7, IGD
Primary Survey:
A: bicara jelas, snorring (-), gurgling (-) -> clear
B: RR 22 x/mnt, SpO2 99% on room air, simetris
(+), KG (-), (sonor/sonor), vesikuler (+/+) --> clear
C: Akral hangat (+), TD 144/84 mmhg, HR 109x, CR
T <2 dtk --> clear
D: GCS E4V5M6, pupil isokor/isokor, RC+/+, RK+/+ T <2 dtk --> clear
--> clear
E : VL di bibir, multipel VE di wajah, tangan, dan k
aki
Initial assessment: No Potential Life Threatening
Bernadus Rasendria Daniswara, L, 18 th, 0
1988197, IGD
Primary Survey:
A: bicara jelas, snorring (-), gurgling (-) -> clear
B: RR 22 x/mnt, SpO2 99% on room air, simetris
(+), KG (-), (sonor/sonor), vesikuler (+/+) --> clear
C: Akral hangat (+), TD 144/84 mmhg, HR 109x, CR
D: GCS E4V5M6, pupil isokor/isokor, RC+/+, RK+/+
--> clear
E : VL di bibir, multipel VE di wajah, tangan, dan k
aki
Initial assessment: No Potential Life Threatening
Secondary Survey:
A: tidak ada Secondary Survey:
M: tidak ada A: tidak ada
P: tidak ada M: tidak ada
L : pukul 19.00 P: tidak ada
E: KLL motor tunggal L : pukul 19.00
E: KLL motor tunggal
Kel.utama:
Nyeri dan luka-luka di pada wajah, tangan, dan ka Kel.utama:
ki Nyeri dan luka-luka di pada wajah, tangan, dan ka
ki
RPS:
1 jam SMRS pasien datang dengan keluhan nyeri RPS:
dan perlukaan di bagian wajah tangan dan kaki. P 1 jam SMRS pasien datang dengan keluhan nyeri
asien mengaku terjatuh sendiri saat mengendarai dan perlukaan di bagian wajah tangan dan kaki. P
motor. Pasien menggunakan helm dan ngebut tet asien mengaku terjatuh sendiri saat mengendarai
api tidak sempat berhenti saat melihat polisi tidu motor. Pasien menggunakan helm dan ngebut tet
r. Helm pasien tidak terlepas. Mekanisme jatuh p api tidak sempat berhenti saat melihat polisi tidu
asien tidak dapat mengingat dengan jelas. Riwaya r. Helm pasien tidak terlepas. Mekanisme jatuh p
t pingsan dan nyeri kepala disangkal. Riwayat nye asien tidak dapat mengingat dengan jelas. Riwaya
ri perut, mual dan mutah di sangkal, BAB (+), BAK t pingsan dan nyeri kepala disangkal. Riwayat nye
(+), flatus (+) riwayat mengkonsumsi alkohol (-). ri perut, mual dan mutah di sangkal, BAB (+), BAK
(+), flatus (+) riwayat mengkonsumsi alkohol (-).
RPD:
Riwayat Asma (-) Alergi (-) , DM (-), HT(-). RPD:
Riwayat Asma (-) Alergi (-) , DM (-), HT(-).
Pemeriksaan Fisik
KU Sedang, E4V5M6 Pemeriksaan Fisik
TD: 144/84 mmHg KU Sedang, E4V5M6
N: 109x/mnt TD: 144/84 mmHg
RR: 22 x/mnt N: 109x/mnt
SpO2 99% on Room air RR: 22 x/mnt
S: 36,5°C SpO2 99% on Room air
S: 36,5°C
Kepala:*
Pupil isokor 3mm/3mm, CA (-/-), SI (-/-), RC (+/+),
RK (+/+)
Upper face
I : simetris, VE (-), VL (-) regio hematoma (-), swelli
ng (-), bleeding aktif (-)
P: sensoris dbn, NT (-), krepitasi (-)
Middle face
I : asimetris , racoon eye (-/-), hematoma (-), telek
antus (-), diplopia (-), gerakan bola mata dbn, ede
ma (-), rhinorrhea (-) , bloody otorrhea (-), battle s
ign (-), deviasi septum nasi (-), step off (-), swellin
g bagian zygoma dextra, VE (+) zygoma dextra dan ign (-), deviasi septum nasi (-), step off (-), swellin
infraorbita dextra,
P : sensoris dbn, floating maxilla (-), NT (-), krepita
si (+) bagian zyogma dextra
Lower face
I : asimetris, avulsi dental (-) VE (+) perioral, labiu
m,dagu, VL(+) Labium oris superior dengan dasar l
uka subkutis, 2x1,cm edema (-), deformitas (-) mal m,dagu, VL(+) Labium oris superior dengan dasar l
oklusi (-), hematoma (-)
P : sensoris dbn, NT (-), gliding mandibula (+) krepi oklusi (-), hematoma (-)
tasi (+) pada regio mandibula sinistra
Leher:
Jejas (-), JVP tidak meningkat, NT (-)
Thorax:
I: Jejas (+) regio clavicula dextra, simetris (+), keti
nggalan gerak (-/-)
P: VF ka=ki
P: sonor/sonor
A: Vesikuler (+ /+), wheezing (-/-), ronkhi (-/-)
Kepala:*
Pupil isokor 3mm/3mm, CA (-/-), SI (-/-), RC (+/+),
RK (+/+)
Upper face
I : simetris, VE (-), VL (-) regio hematoma (-), swelli
ng (-), bleeding aktif (-)
P: sensoris dbn, NT (-), krepitasi (-)
Middle face
I : asimetris , racoon eye (-/-), hematoma (-), telek
antus (-), diplopia (-), gerakan bola mata dbn, ede
ma (-), rhinorrhea (-) , bloody otorrhea (-), battle s
g bagian zygoma dextra, VE (+) zygoma dextra dan
infraorbita dextra,
P : sensoris dbn, floating maxilla (-), NT (-), krepita
si (+) bagian zyogma dextra
Lower face
I : asimetris, avulsi dental (-) VE (+) perioral, labiu
uka subkutis, 2x1,cm edema (-), deformitas (-) mal
P : sensoris dbn, NT (-), gliding mandibula (+) krepi
tasi (+) pada regio mandibula sinistra
Leher:
Jejas (-), JVP tidak meningkat, NT (-)
Thorax:
I: Jejas (+) regio clavicula dextra, simetris (+), keti
nggalan gerak (-/-)
P: VF ka=ki
P: sonor/sonor
 A: Vesikuler (+ /+), wheezing (-/-), ronkhi (-/-)
Abdomen:
I: Distensi (-), jejas (+) Abdomen:
A: BU (+) I: Distensi (-), jejas (+)
P: Supel, defans (-), NT (-) A: BU (+)
P: timpani (+)   P: Supel, defans (-), NT (-)
P: timpani (+)  
Pelvis:
I: Jejas (-) Pelvis:
P: NT (-), Krepitasi (-) I: Jejas (-)
P: NT (-), Krepitasi (-)
Ekstremitas:
Akral hangat (+), CRT <2 detik Ekstremitas:
Akral hangat (+), CRT <2 detik
Status lokalis regio manus dextra
L : tampak deformitas pada digiti I, multipel VE(+) Status lokalis regio manus dextra
VL(-) L : tampak deformitas pada digiti I, multipel VE(+)
F : NT(+) pada digiti I VL(-)
M : ROM digiti I terbatas nyeri F : NT(+) pada digiti I
M : ROM digiti I terbatas nyeri
Status lokalis regio manus sinistra
L : tampak deformitas dan shortening pada digiti Status lokalis regio manus sinistra
V, multipel VE(+) VL(-) L : tampak deformitas dan shortening pada digiti
F : NT(+) pada digiti V V, multipel VE(+) VL(-)
M : ROM digiti V terbatas nyeri F : NT(+) pada digiti V
M : ROM digiti V terbatas nyeri
Status lokalis regio genu sinistra
L : deformitas (-) shortening (-), jejas (+) VE(+) VL Status lokalis regio genu sinistra
(-) L : deformitas (-) shortening (-), jejas (+) VE(+) VL
F : NT(+) krepitasi (-) (-)
M : ROM terbatas nyeri F : NT(+) krepitasi (-)
M : ROM terbatas nyeri
Ass:
- CKR Ass:
- Vulnus laceratum regio labium oris superior - CKR
- Fraktur neck of condyle mandible sinistra
- fraktur zygomaticomaxillaris dextra
- Multiple VE regio facial
- Multiple VE regio manus dextra et sinistra
- Multiple VE regio genu sinistra
- Trauma tumpul abdomen dengan HD stabil
- Susp. Fraktur clavicula dextra
- Susp. Fraktur digiti I manus dextra
- Susp. Fraktur digiti V manus sinistra
- Susp. Fraktur genu sinistra
Plan: usul
- Wound toillete
- O2 NK 3 Lpm
- Head up 30°
- IVFD NaCl 0.9% 20 tpm
- Cek lab lengkap, swab antigen
- MSCT 3D kepala tanpa kontras + rekon
- Ro cervical, Ro thorax, Ro Pelvis
- Ro clavicula dextra AP Cephalad
- Ro manus bilateral
- Ro genu sinistra
- Inj. ATS 1A
- Inj. Ceftriaxon 1gr/ 12 jam
- Inj. Ketorolac 30mg/ 8 jam
- Inj. Ranitidin 50mg/ 12 jam
- Rawat luka VE dengan salep chlorampenicol
- Primary suturing regio labium superior dengan vi - Rawat luka VE dengan salep chlorampenicol
cryl 4.0 (dalam), 5/0 luar
- Pro reconstruction of facial bone elektif
- Konsul B. Saraf bila ada kelianan CT Scan kepala
- konsul digest jika ada kelainan
- Konsul B. Plastik, Orthopedi
- Swab antigen, konsul UPD terkait bangsal isolasi
- Vulnus laceratum regio labium oris superior
- Fraktur neck of condyle mandible sinistra
- fraktur zygomaticomaxillaris dextra
- Multiple VE regio facial
- Multiple VE regio manus dextra et sinistra
- Multiple VE regio genu sinistra
- Trauma tumpul abdomen dengan HD stabil
- Susp. Fraktur clavicula dextra
- Susp. Fraktur digiti I manus dextra
- Susp. Fraktur digiti V manus sinistra
- Susp. Fraktur genu sinistra
Plan: usul
- Wound toillete
- O2 NK 3 Lpm
- Head up 30°
- IVFD NaCl 0.9% 20 tpm
- Cek lab lengkap, swab antigen
- MSCT 3D kepala tanpa kontras + rekon
- Ro cervical, Ro thorax, Ro Pelvis
- Ro clavicula dextra AP Cephalad
- Ro manus bilateral
- Ro genu sinistra
- Inj. ATS 1A
- Inj. Ceftriaxon 1gr/ 12 jam
- Inj. Ketorolac 30mg/ 8 jam
- Inj. Ranitidin 50mg/ 12 jam
- Primary suturing regio labium superior dengan vi
cryl 4.0 (dalam), 5/0 luar
- Pro reconstruction of facial bone elektif
- Konsul B. Saraf bila ada kelianan CT Scan kepala
- konsul digest jika ada kelainan
- Konsul B. Plastik, Orthopedi
/ non isolasi - Swab antigen, konsul UPD terkait bangsal isolasi
/ non isolasi