Download - Mekong Orto Tanggal 2 Sept 2015
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DK/F/32 years old
3/09/2015
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• 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
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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
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Secondary Survey
Head: normal limitNeck : normal limitChest : localized stateAbdomen : normal limitExtremities superior : normal limitExtremities inferior : normal limit
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Localized state
Chest :look : swelling (+), deformity (+), hematom (+) regio left clavicula.Feel : pain (+), NVD (+), crepitation (+).Move : ROM (+) decrease, DOF (+) .
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Clinical photo
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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
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Chest X-Ray
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Working Diagnose
(L) Middle 3rd clavicle fracture
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Treatment
• IVFD RL 20 drop/i• Inj. antibiotics• inj. Analgetic• arm sling Plan: ORIF elective
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Post arm sling
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THANK’S FOR YOUR ATTENTION