Patient name : Anna Saveleva

Patient complains : pain on the lower right ribs

Date of first complains : 09/06/2020

Date of consultation : 16/06/2020

Patient complains:

Patient complains of having pain on lower right ribs after fall and hit the concrete a week ago. The pain
is getting worse now. She felt the pain getting worse especially when she move to right and left and
when deep inhale. No fever, coughing reported

General condition :

Compos mentis

Good

On examination:

Airway : clear,

Breathing : 16x/mnt, regular, Po : vesicular +/+, no rh -/-, no wh -/-

Circulation : BP : 130/80mmHg, saturatioO2 98-99%

Disability : GCS E4V5M6

Exposure :
Regio costa D

L : no swollen, no hyperemic, no deformitas

F : no crepitation, pain on palpation + VAS 7-8

M ; ROM limited due to pain

Lab result:

Planning to X-ray at hospital

Diagnosis :

Suspect simple close fracture costa D ddx/contusion muscularum ddx/contusion ligamentum

Treatment :

Chlor etyle spray

Pirofel gel

Patient refused to get pain killer injection and oral

Medicine : -(refused by patient)

Recommendation:

Recommended to get X-ray in the hospital

Bed rest