R/ F/ 59YO

65.66.70
Chief Complaint : Pain on the chest
It has been suffered since 24 hours before admision to Haji Adam
Malik Hospital. Previously, patient got car accident, hit a wall from the
front side, patient didnt use seatbealt. Shortness of breath (-),
Abdominal pain (-), flatus (+). History of unconciousness (-), nausea
(+), vomiting (+), seizure (-).
Primary Survey :
A : clear
B : spontaneus, RR 24 x/mnt
C : warm acral, BP 110/70, HR 90 x/mnt
D : full alert, CGS 15 (E4M6V5)
E : undress and log roll deformity in left arm
Vas : 7
 Generalized State :
Head : hematome o/t right eye
Neck : no abnormality was found
Chest : in localized state
Abdomen : no abnormality was found
Extremity : in localized state
Localized State :
Chest : L : symetric, bruise (-), lag of movement (-)
L : vesicular on both hemithorax
F : resonance on both hemithorax
Laboratorium Findings :
Hb/Hct/Leu/Plt : 11.10/ 33.0/8.38/216
Ur/Cr : 68.30/ 1.13
Na/K/Cl : 141/3.4/106
Random Blood Glucose : 92.30
Schaedel X ray
Cervical X ray
Chest X ray
Fore arm X ray
Pelvic X ray
Head ct scan
Working Diagnosis
Head injury GCS 15 + closed (L) posterior 3rd rib fracture + (R) closed
posterior 1st-3rd ribs fracture + (R) Zygoma fracture + Closed (L)
middle clavicle fracture + Closed (L) Stiloradius fracture + Pelvic
fracture tile tipe A1
Treatment at Emergency Room :
IVFD Crystalloid
Inj. Antibiotic
Inj. Analgetic
Inj. H2 Agonist
Insertion urin catheter came out 400 cc urine clear yellow
Pelvic sling
Pain management + conservative treatment
CT pelvic 3D refusal medical advice
ORIF clavicle, stiloradius, zygoma refusal madical advice