3. Airway : can talk , no c-spine tenderness
Breathing : equal breath sound both lungs ,
no dypsnea , chest compression test negative
Circulation : BP 127/94 mmHg , PR 81 bpm ,
no abdominal tenderness , no active bleeding
4. Disability : E4V5M6 , pupil 2 mm RTLBE
Exposure : tender at Left shoulder with
stepping , ablasion wound both knee
5. A : no need
B : Flim Chest PA view
C : Flim Pelvis AP view
D : no need
E : Flim shoulder Left (AP ,transcapular view)
6. Allergy : no drug allergy
Medication : none
Past history : no underlying disease
Last meal : 12.00 PM
8. Physical examination
◦ Vital signs : T 36.1 C, PR 81 bpm , RR 20/min , BP
127/77 mmHg
◦ General appearance : good consciousness , well
cooperative
◦ HEENT : no pale conjuctivae , anicteric sclerae , no
contusion at head
◦ CVS : normal S1 , S2 , no murmur
9. Chest : tender at Left distal 1/3 at clavicle ,
strepping , equal breath sound both lungs
Abdomen : soft , not tender
Pelvis : not tender
Extremities : no deformities ,no limit ROM at
shoulder , ablasion wound at both knee 1 x1
cm
10. Neuro : E4V5M6 , pupil 2 mm RTLBE , motor
Gr.V all extremities , sensory intact
11. Mild head injury (moderate risk) with tender
at Left shoulder
12.
13.
14.
15.
16. Left shoulder AP & transapular view
◦ Transverse fracture at distal 1/3 of left clavicle , no
displacement ,
17. Mild head injury (moderate risk) with close
fracture at Left clavicle
18. On arm sling 1-2 wk
Advice : Lifestyle modification , complication
Pain controls
