DEPARTEMENT OF SURGERY

20 th december 2014

 Name

: Mrs. Siti muanik

Age
: 28th y.o
Sex
: female
Address
: lamongan
Date examination: 19th des, 2014

anamnesis
Chief complaint

Left shoulder pain

MOI
Patient came with left shoulder pain post traffic

accidents. Patient was riding a motorcycle, helmet

+, sudden loss of balance when going to deflect her
motorcycle.Then, she fell to the position of the left
shoulder hit the asphalt and she felt there was a "
kretekk " in his left shoulder that time.
unconscious-, PTA -, vomiting -, nausea -, headache
-, abdominal pain -, bloody rhinorea bloody
othorrea -, short of breathing -

Vital sign :
BP : 129/53
P : 90
RR: 20x
T : 36

 Airway and spine control : clear (+),

snorring (-), gargling (-), potensial
obstruction (-). C-spine normal
Breathing : spontan, simetric (+), RR
20x/minutes, ves/ves, rh-/-, wh-/-, Sp02
100% with O2 support
Circulation : PR 90x/minutes, acral warm
dry red, CRT < 2, BP 129/53 mmhg
Disability : GCS 456, LP +/+, isocor pupil
3mm/3mm, lateralisasi Exposure : temp 36C

Secondary survey
Head and neck : anemic (-), icteric (-),

cyanosis (-), dyspneu (-), scalp hematom

(-), vulnus (-)
Thorax : simetric (-), retraction (-), lesion (-)
Pulmo : ves/ves, rh-/-, wh-/Cor : S1S2 single, murmur (-), gallop (-)
Abdomen : lesion (-), flat, distended (-),
tympani (+), liver and spleen were not
palpable, bowel sound (+), pelvic stable,
pain (-)
Extremities : acral warm, dry, red, CRT< 2

Status localized
Et regio shoulder sinistra :

L : soft tissue swelling +, skin intact +,

deformity +
F : painful +, distal arterial pulsation +,
krepitasi +, sensibility +
M : ROM limited due to pain, abnormal
movements -

Clue and cue :

Female, 28 yo
Post traffict accident
Left shoulder pain
Krepitasi +
GCS : 456

t
h
o
r
a
x

asessment
Close fracture clavicula 1/3 medial displace

therapy
IVFD assering 1500 cc/24 jam
Remopain 3x30 mg iv
Acran 2x1 amp iv
C/ Sp.OT pro ORIF

 Vital sign
GCS
sign of increased pressure intracranial

 Explain to the patients family about the

diagnosis, etiology, intervention of therapy,

complication, and prognosis.