Departement of SURGERY

Shofa, 20 January 2015

(14.00 pm- 07.00 am)

Identity
Name
Age
Address

: Mrs. M
: 55 YO
: Lamongan

Anamnesis
Chief

complaint:
Pain in the left arm
MOI :
Patient came with pain in the left arm since 1 hours
post traffic accidents complains. Patient riding
motorcycle with a helmet and she was hitten by
motorcycle from left side. She fell tengkurap
position, pingsan (+) about 5 minute, Nausea (-),
vomit (-), PTA (+), headache (-).

History or past illness :

HT (-),
DM (+) since 15 years ago and routine controled
and consumed glucodex 2x1.

History of family: -

History of sociality:
- Smoke
- Alcohol
- Herbal Medicine

 PRIMARY SURVEY
Airway

:
Clear -, snoring-, gurgling Breathing :
I : simetric bilaterally+
A : ves/ves, rh-/-, whz-/P : ICS normal
P : sonor/sonor
RR : 22x/minute, SPO2= 98%

 Circuration

and bleeding control :

BP : 131/80 mmHg
Pulse Rate : 28x/minute, regular
Acral : Warm and dry to touch Red
CRT : < 2 seconds
Disability :
GCS 456
Pupil round isokor 3mm, light reflex +/+
Lateralisasi -

 Exposure

:
Regio Frontal dextra Vulnus abrasio
Regio maxila dextra Vulnus abrasioio
Reg Thorax Vulnus abrasio
T : 35,4C

Secondary Survey :
KL:
anemis -/-, icterik -/-, cyanosis -/-, dysp
Oksipital sin Vulnus appertum 3x1 cm
Thoraks :
I : pergerakan dinding dada simetris, retraksi (-), jejas (+)
P : fremitus (+), simetris
P : sonor/sonor
A : cor : reguler , S1 S2 tunggal, suara tambahan
pulmo : simetris (+), ves /ves, rh -/-, wh -/ Abdomen :
I : flat, jejas (-)
A : BU (+) N
P : supel, nyeri tekan (-), Hepar lien tidak teraba,
P : timpani, timpani,
Ekstremitas :Akral HKM, CRT <2 detik, Regio manus dextra Vulnus
abrasio, Regio patela Dex et sin Vulnus abrasio, Regio anthebrachii
sinistra Vulnus abrasio

Status Neurologis
GCS : 456
Pupil equal 3 mm, LR +/+)
Motoric
Upper extremit 5/5
Lower Extremity 5/5
Sensoric
Upper extremity +/+
Lower extremity +/+

Laboratory Findings
Diff count: 1/3/86/7/3
Hematocrite: 20,5
Hb 6,4 mg/dl
Leukocytes : 8300
Thrombocyte : 128.000
GDA 248
Bleeeding Time : 200
Clothing time : 900

CT-SCAN
(brain window)

CT-SCAN
(bone window)

Clue and Cue

Female, 55 yo
Pain in the left arm
Post traffic accidents
Nausea (+)
PTA (+)

GCS 456
Regio humeri sinistra Vulnus
abrasio et appertum

PROBLEM LIST
Fr.

Displace et regio
Humeri sinistra

 Planning
Planning
-

Dx : -

Tx :
Arm slim
IVFD NaCl1500cc/24 jam
Inj Remopain 1 amp iv
Inj Santagesic 3x1 amp
Inj Acran 2x50 mg
RCI extra 4 iv
Consult Sp, OT
Consult Sp.PD
Consult Sp.J

Prognosis
Dubia

ad Bonam

Education
Explaine

to the family about the disease of the

family, about its theraphy and intervention will be
done, and also about complication and prognosis .

Take

a planty of rest

Thank you