Morning Conference

Wednesday, 13th August 2015

DH/M/13 yo

Chief Complaint :
Loss of consciousness
It has been suffered since 10 hours ago before
admitted to Pirngadi General Hospital (PGH). Initially,
the patient was riding a motorcycle, and tried to
avoid a stone on the street. But, the patient was
failed and falling down from his motorcycle.
Vomiting (-). Nausea (-). Convulsions (-). Patient
had initial resuscitation in Kutacane General Hospital
than referred to the PGH.
History of medicine: Inj. Ceftriaxone 1 gr, inj.
Ranitidin 50mg, inj. Ketorolac 30mg, inj. Tramadol
100mg

PRIMARY SURVEY
Airway : Clear, with nasal canule 3 lpm
Breathing : Spontan, RR : 24x/minute
Circulation : Warm acral, Pulse:
100x/minute
Blood Pleasure : 110/70 mmHg
Disability : GCS 12
Exposure : Secondary survey

SECONDARY SURVEY
Head
Eye : Pupil isochors (+), conjunctiva anemic (-/-), sclera icteric (-),
Left eye: Swelling (+), contusion wound (+)
Regio temporalis : Excoriated wound (+) 3cm x 5cm
Regio zygomatical : Excoriated wound (+) 4,5cm x 2cm
Regio buccalis
: Excoriated wound (+) 5cm x 3cm
Ear : No abnormality found
Nose : Nasal canul attached (+), NGT attached (+), fluid: clear
Mouth : Left upper lip: lacerated wound (+) 1cm x 0,3cm, irreguler
Neck : No abnormality found

Thorax
Look : Symmetric, lesion (-)
Listen : Vesiculer
Feel
: Sonor
Abdomen
Look : Symmetric, lesion (-)
Listen : Peristaltic (+) N
Feel
: Smooth
Extremity
Upper
Lower

: Elastic verban attached (+),

Excoriated wound (+) on the left elbow
: No abnormality found

Genitalia
Male, urinary catheter attached (+), urinary production: 200cc

Status localization
Left Clavicula
Look : Excoriated wound 4 x 3 cm,
Swelling (+), deformity (+)
Feel : pain (+), NVD (+)
Move : ROM (+), DOF (+)

Clinical Photo

Photo Cervical Lateral

Photo Thorax AP

Laboratory test

(13/8/2015)

WBC/ HGB/ HCT/ PLT: 17.200/ 10,8/ 33,2/

286.000
Neu
: 88%
Glucose Adr
: 114 mg/dl
Na/K/CL
: 134/4,90/113
Blood gas analysis:
pH
: 7,57
PCO2 : 20,7mmHg
PO2 : 143,2mmHg
HCO3 : 19,4mmol/L
BE
: -2,8mmol/L

Diagnosis
HI GCS 12
(L) middle third clavicle transversal
fracture
Multiple excoriated wound
Lacerated wound o/t upper lips

Therapy emergency room:

IVFD RL
Inj. Antibiotic
Inj. Analgetic
Inj. ATS
Plan:
Primary suture + wound toilet
Arm sling
ORIF elective

Post Op