IDENTITY

Name : Mr. T
Age : 13 years old
Address : BTN Kendari permai
Admission : April, 4th 2018
DPJP : dr. Rizal Alisi , Sp.OT
 HISTORY TAKING
• Main complain : pain at left chest
• Anamnesis :
Suffered since 6 hours ago after traffic accident
• Mechanism of trauma :
Patient with his friend was riding motorcycle at moderate speed, not using
helmet, and then he fell from his motorcycle into the gutter . Position of fell down
was unknown
• There was history of unconsiousness.
• There was no history of nausea and vomitting
• There was no bleeding from nose (-), mouth (-), ears (-).
• There was no history of consumpting alcohol
 Primary survey
A Clear

RR 44x/min, spontaneous,
symmetrical B
C BP : 90/60 mmhg,
HR = 112x/min, regular, Weak

GCS 15 (E4M6V5), pupil isochors, D

E T = 36,70 C (axillary)
 SECONDARY SURVEY

Head : Within Normal Limit

Eyes : Within Normal Limit
Nose : Within Normal Limit
Mouth : Within Normal Limit
Neck : Within Normal Limit
Chest : Localized State
Abdomen : Localized State
Upper limb : Localized State
lower limb : Localized State
 LOCALIZED STATE
Face :
I : Swelling (+) at frontal regio, Hematoma (+) at
orbitalis regio D/S. Post Hecting at labia superior.
P : tenderness (+)

Thorax
I : swelling (-), hematoma (-), wound (-)
P : tenderness (+) at righ site, crepitation (-)
P : sonor (+)
A : vesiculer ( + /+)
Abdomen :
I : dome shaped, follow the motion of breath.
A : Peristaltic was normally
P : Tenderness to palpation at lower regio (+),
P : Tympani (+)
Lumbalis Posterior Sinistra
I : Hematoma (+), deformitas (-), wound (+) with hecting situation.
Vulnus exoriatum (+).
Left Lower Limb sinistra:
Attached spalk, tenderness (+).
ROM : can not be assessed
NVD ; Sesibilitas (+), pulsation of dorsalis pedis arteri (+), CRT , 2’.
Plan of Diagnostic

• Rountine Blood
• X-Ray Thorax PA
• X-Ray Femur Ap/Lat
• USG Abdomen
Clinical Finding
Diagnosis

Multiple Trauma
 MANAGEMENT
• IVFD
• Resucitation (
• Analgetics
• H2RA
• Antibiotics
• Wound care
• Consult to general surgeon
Thank You