mekong orto tanggal 2 sept 2015

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DK/F/32 years old

3/09/2015

• Chieft complaint : Left shoulder difficult to move• It has been suffered since 2 days before became

to Emergency Unit Pirngadi General Hospital. Previously, patient crushed from motorcycle because patient tried to avoid the another motorcycle. And patient fall down to left. Vomiting (-), headache (-), history of unconsciousness (-). Dyspnea (-), Defecation (+) normal. Urination (+) normal

• Previous disease : unknown• Previous medication : unknown

Primary Survey

• A: Clear• B: spontaneus, RR : 20x/minute• C: warm acral, BP : 110/60 mmHg, HR:

80x/minute, UOP: 100 cc/hour clear yellow• D: GCS 15• E: undress, logroll

Secondary Survey

Head: normal limitNeck : normal limitChest : localized stateAbdomen : normal limitExtremities superior : normal limitExtremities inferior : normal limit

Localized state

Chest :look : swelling (+), deformity (+), hematom (+) regio left clavicula.Feel : pain (+), NVD (+), crepitation (+).Move : ROM (+) decrease, DOF (+) .

Clinical photo

Laboratory

• Hb/Ht/Leu/Tro : 10,8/35/21.800/443.000• Random Blood Glucose : 112 mg/dl• Na/K/Cl : 144/3/108• Urinalysis: in normal limit

Chest X-Ray

Working Diagnose

(L) Middle 3rd clavicle fracture

Treatment

• IVFD RL 20 drop/i• Inj. antibiotics• inj. Analgetic• arm sling Plan: ORIF elective

Post arm sling

THANK’S FOR YOUR ATTENTION

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