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Sugianto/M/70yo
Closed (R) Midshaft Clavicle Fracture Allman Classification Type I
Closed (R) Acromion Fracture Kuhn Classification Type I
HI GCS 13
Burst Lobe o/t (L) FTP
Multiple (R) Costae Fracture (3,4,5,6,7)
Performed at ER :
Arm Sling
(Monday, January 15th 2024)
ICD X : S42.0, S42.12
ICD IX : 93.53
History
Chief Complain: Pain on the right shoulder
He has suffered since 7 hours ago. History of trauma (+). The patient fell off the motorcycle as he avoided a hole in
the road. The mechanism of trauma is unclear. After the incident, the patient was not able to raise his shoulder due
to pain, ear bleed was found. Shortness of breath (-), nausea (-), vomiting (-), fainting (-), history of alcohol
consumption (+) before he headed out on his motorcycle. Then the patient was taken to Haji Hospital, Xray, CT scan
of the head, and wound sutures on the head were done. The family then took the patient home and was taken to
Haji Adam Malik Hospital for further treatment.
History of loss of consciousness : (-)
History of past illness : (-)
History of medication : (-)
History of food/drug allergies : (-)
Secondary Survey
• Head
• Eye : Pupil isochor equal 3mm/3mm,
sclera normal, conjunctiva normal
• Nose : Normal
• Lips : Normal
• Ears : Normal
• Neck : Lymph node normal, trachea deviation (-)
• Chest : Emphysema Subcutaneous, Vesicular, rh
-/-, wh -/-, heart sound normal
• Abdomen : Normal
• Genitalia : Male, no abnormalities
• Extremity : Normal
Primary Survey
A : clear
B : spontaneous, RR 20 times per
min
C : stable, BP: 130/80 mmHg, HR
74
D : Somnolen, GCS E3M6V4
E : localized state
Localized State:
(R) Shoulder
L: Swelling (+), deformity (-), Asymetrical Shoulder (+),
bruise (+), open wound (-), excoriated wound (-), skin
tenting (-),
F: tenderness (+), crepitation (+), radial & ulnar arteries
were palpable, sensory R/M/U +2/+2/+2
M:
AROM shoulder joint limited d/t pain
AROM elbow joint normal
AROM wrist joint normal
AROM all fingers normal
Shoulder AP Xray
January 16th 2024
Adam Malik
Hospital
15˙
Scapular Y view Xray
January 16th 2024
Adam Malik Hospital
Laboratory
January 16th
2024
Adam Malik
Hospital
List of Problem:
• Pain
• Limited Motion
Diagnosis:
• Closed (R) Clavicula Midshaft Fracture Allman Classification Type I
• Closed (R) Acromion Fracture Kuhn Classification Type I
• HI GCS 13
• Burst Lobe o/t (L) FTP
• Multiple (R) Costae Fracture (3,4,5,6,7)
Performed at ER (Monday, January 16th 2024) :
• Arm Sling
• Plan :
Conservatif Treatment with Armsling
Arm Sling
Timeline
14.29 - patient register
14.40 - orthopedic residents examine1
4.43 - Neurosurgeon residents examine
14.48 - General surgery residents examine
14.54 - WO X-Ray
15.20 - sent to radiology department
16.15 - Finished X-Ray & CT- Scan
16.29 - Orthopaedic assessment
16.34 - Laboratorium results
16.45 - USG FAST from General surgery
18.05 - Consult to Anesthesiologist
19.15 - Patient sent to OT Room
21.20 - Surgery starts
00.05 - Surgery finished
01.20 - Patient sent to Radiologic department for post operativr x ray
01.36 - Patient sent to ward

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Laporan pasien trauma tim jaga 20231226 (1)

  • 1. Sugianto/M/70yo Closed (R) Midshaft Clavicle Fracture Allman Classification Type I Closed (R) Acromion Fracture Kuhn Classification Type I HI GCS 13 Burst Lobe o/t (L) FTP Multiple (R) Costae Fracture (3,4,5,6,7) Performed at ER : Arm Sling (Monday, January 15th 2024) ICD X : S42.0, S42.12 ICD IX : 93.53
  • 2. History Chief Complain: Pain on the right shoulder He has suffered since 7 hours ago. History of trauma (+). The patient fell off the motorcycle as he avoided a hole in the road. The mechanism of trauma is unclear. After the incident, the patient was not able to raise his shoulder due to pain, ear bleed was found. Shortness of breath (-), nausea (-), vomiting (-), fainting (-), history of alcohol consumption (+) before he headed out on his motorcycle. Then the patient was taken to Haji Hospital, Xray, CT scan of the head, and wound sutures on the head were done. The family then took the patient home and was taken to Haji Adam Malik Hospital for further treatment. History of loss of consciousness : (-) History of past illness : (-) History of medication : (-) History of food/drug allergies : (-)
  • 3. Secondary Survey • Head • Eye : Pupil isochor equal 3mm/3mm, sclera normal, conjunctiva normal • Nose : Normal • Lips : Normal • Ears : Normal • Neck : Lymph node normal, trachea deviation (-) • Chest : Emphysema Subcutaneous, Vesicular, rh -/-, wh -/-, heart sound normal • Abdomen : Normal • Genitalia : Male, no abnormalities • Extremity : Normal Primary Survey A : clear B : spontaneous, RR 20 times per min C : stable, BP: 130/80 mmHg, HR 74 D : Somnolen, GCS E3M6V4 E : localized state
  • 4. Localized State: (R) Shoulder L: Swelling (+), deformity (-), Asymetrical Shoulder (+), bruise (+), open wound (-), excoriated wound (-), skin tenting (-), F: tenderness (+), crepitation (+), radial & ulnar arteries were palpable, sensory R/M/U +2/+2/+2 M: AROM shoulder joint limited d/t pain AROM elbow joint normal AROM wrist joint normal AROM all fingers normal
  • 5.
  • 6. Shoulder AP Xray January 16th 2024 Adam Malik Hospital 15˙
  • 7. Scapular Y view Xray January 16th 2024 Adam Malik Hospital
  • 9.
  • 10. List of Problem: • Pain • Limited Motion Diagnosis: • Closed (R) Clavicula Midshaft Fracture Allman Classification Type I • Closed (R) Acromion Fracture Kuhn Classification Type I • HI GCS 13 • Burst Lobe o/t (L) FTP • Multiple (R) Costae Fracture (3,4,5,6,7) Performed at ER (Monday, January 16th 2024) : • Arm Sling • Plan : Conservatif Treatment with Armsling
  • 12. Timeline 14.29 - patient register 14.40 - orthopedic residents examine1 4.43 - Neurosurgeon residents examine 14.48 - General surgery residents examine 14.54 - WO X-Ray 15.20 - sent to radiology department 16.15 - Finished X-Ray & CT- Scan 16.29 - Orthopaedic assessment 16.34 - Laboratorium results 16.45 - USG FAST from General surgery 18.05 - Consult to Anesthesiologist 19.15 - Patient sent to OT Room 21.20 - Surgery starts 00.05 - Surgery finished 01.20 - Patient sent to Radiologic department for post operativr x ray 01.36 - Patient sent to ward