1. Arya Darmawan / M / 19 yo / BPJS
T.arr :23.00 T.acc : 21:00 CM : 23068459
• Present History:
– Conscious patient complained pain on his right shoulder after accident 2
hours prior to admission
– Onset : 2 hours prior to admission
– Site : Right shoulder
– Quality : Sharp pain
– Quantity : Continuous
– Chronology : Patient was riding motorcycle suddenly hit other motorcycle
from and fell to the right side with his right shoulder hit the asphalt.
– Influencing Factor: Pain was aggravated by movement and get better at
rest
– Associated Factor: History of unconsciousness (-), nausea (-), vomiting (-).
2. • Past History:
– Allergic : -
– Medication : -
– Past Medical History : -
– Last Meal : 4 hours prior to admission
Social History:
– Patient works as sales and right handed dominant,
Primary Survey:
A : Clear
B : Spontaneous, RR 20 x/min, Sp. O2 99% room air
C : Stable, BP 120/80 mmHg, HR 85 x/min
D : Alert
3. Secondary Survey:
GCS E4V5M6
Head : Cephalhematoma (-)
Facial : bruise (-)
Eye : Anemic conjunctiva -/-
ENT : Otorrhea -/-, rhinorrhea -/-
Thorax :
Insp : Symmetric, bruise (-)
Palp : Tenderness (-)
Perc : Sonor/sonor
Aus : Cor: S1S2 single reguler murmur (-)
Po: Ves +/+, rh -/-, whe -/-
Abdomen :
Insp : Distension (-)
Aus : BS (+) N
Palp : Defans (-)
Per : Tympani
Extremities : Warm
~ Local status
4. Right Shoulder Region
L : Swelling (+) around anterior side, bruise (-), deformity (+), skin tenting (+)
F : Tenderness (+) at clavicle middle third, radial artery palpable, CRT<2, SpO2 98%, normal
sensation
M :
Active ROM shoulder limited due to pain
Active ROM elbow 0/135
Active ROM wrist 80/90
Active ROM MCP-IP 0/90
5. Assessment :
CF Right Clavicle Middle Third
dd/ CF Right Clavicle Distal Third
Imaging :
Right Shoulder X-Ray AP View (Prof. Dr. IGNG Ngoerah Hospital)
7. Diagnosis:
CF Right Clavicle Middle Third Allman Group I (AO15.2A) (S42.001A)
Planning of Diagnostic:
-
Treatment:
- Analgetic
- Immobilization with armsling
Planning of Treatment :
ORIF PS (Elective)
Court-Brown, C.M., Heckman, J.D., McQueen, M.M., Ricci, W.M. & Tornetta, P. 2014. Rockwood and Green’s Fractures in Adults, 8th ed. Philadelphia, USA, Wolters Kluwer
