Morning Report

August, 20th 2011

Patient Mr.R, male, 24 years old,

came to AA Hospital on 18 August
2011

Chief complain:
unconscious after motorcycle accident

Primary Survey

Airway: clear
Breathing: breathing spontanly with
respiration rate 20 x/minute
Circulation: BP 110/80 mmHg, HR:
88x/minute regular and warm acral,
capilery refillied <2 seconds
Disability: GCS 15, pupil isochor 3
mm/ 3mm,light reflect (+/+).
Exposure: prevent hipotermia with

cover.

Secondary Survey

Recent Illness History

5 hours ago, patient drove a motorcycle (no using
helmet) which speed was 60km/h. When he turn
to the left, suddenly a women passing through and
he crush her. Then, his motorcycle fell down to the
left and then he was unconscious.
Then, he was brought to AA hospital
At hospital he was conscious and feel mild
headache,pain around his left shoulder. There was
no vomit,blood from ear and from nose.

Past illness history : no related

Family illness history: no related

Physical Examination

Conciousness : composmentis
Vital sign:

BP: 120/80 mmHg

HR: 89 x /minutes
RR: 19 x/minutes
Temp:37,10C

Head
Inspection:

Vulnus excoriatio at os.parietal

(3 x 4 cm)
No Otorea
No Rhinorea
No Raccoon eyes

Thorac
Abdominal
Flank
Genitalia
Extremity

:
:
:
:
:

Normal
Normal
Normal
Normal
Localized

Local Status
Left shoulder
Look
Swelling (-), laceration (-),
deformity (-),shortening (-),cyanosis (-)
Feel
Pain (+)
Warm (+)

Move : limited active and pasive

movement.

Rontgen from emergency unit

Working diagnose

Mild head injury + suspect fractur

around left shoulder

Differential Diagnose

Mild head injury + fractur caput

humery
Mild head injury + fractur distal
clavicula

Examination Planning

Rontgen AP and lateral left shoulder

( thats show articulatio humeri
sinistra and clavicula sinistra )

Laboratory findings
Hb
Ht
WBC
PLT

: 16 gr/dl
: 49 %
: 17.000 /L
: 238.000 /L

Treatment

IVFD RL
Inj ceftriaxon 3x1 amp
Mefenamic acid tab 3x1

Thank You