Patient identity

Name : M
Age : 22 years old
Sex : Male
Address : Ganda Pura, Bireuen
Admission time : 18.34
Drive license : (+)
Time response
Date/Time Examination Laboratory Radiology Time of Date/Time DPJP
patient hour Examination Examination Diagnostics patient
came to ER out from
Send Result Send Result ER

May 13th 18.36 19.15 20.30 20.15 21.00 21.15 May 13th
2019 Wib Wib Wib Wib Wib Wib 2019
18.34 23.00
Wib Wib

Chief Complain
• Pain and difficult to move right arm
History of present illness
• The patient was referred from jeumpa bireun district hospital to Zainoel Abidin emergency
room with chief complain pain and difficult to move right arm since 2 day ago.
• Initially the patient riding tractor and suddenly he slip and then he fell of to asphalt.
• Patient also complain wound and pain at the head, facial, and his body after trauma.
• There were no history of nausea and vomiting.
• Eyes open spontaneously, motoric obey command and verbal oriented.
• Patient already debridement wound, scrubbing in district hospital.
• Radiology already performed at distric hospital.
Physical examination :
Primary survey
• A : Clear
• B : Spontaneous, RR = 18 breaths/minute
• C : BP : 110/70 mmhg, Pulse : 86 beats/minute, warm acral, IVFD RL 1500 cc/24 jam
• D: GCS = E4 M6 V5 = 15, isochoric pupil (3mm/3mm), light reflex (+/+)
E:
L/S at Head Region
Look : Lacerated wound (+) 6x1 cm at the parietal region already suture, swelling (+)
Feel : Pain (+), step off deformity (-)
L/S at the upper face
Look : symmetrically, Lacerated wound (+) 4x1 cm at the right frontal region, swelling (+)
Feel : Pain (+), step off deformity (-)
L/S at the middle face
Look : Symmetrically, wound (-) , swelling (-)
Feel : Pain (+), step off deformity (-)
Visus & Eye Movement :
• 2/2
L/S at the lower face
Look : Swelling (-), excoriated wound (+) 3x2 cm at the right and left cheek region,
excoriated wound (+) 2x2 cm at the chin region, lacerated wound (+) 2x0,5 cm at the lower lips
Feel : Pain (+), step off deformity (-)
L/S Intra oral
• Maloclussion (-)
• Dental loss (+) at the right upper incisivus
• Lacerated wound 2x0,5 cm already suture
• Upper extremity
• L/S at the left arm
Look : Swelling (-), deformity (-), excoriated wound (+), lacerated wound (+) 4x1 cm was
suture
Feel : Pain (+), NVD (-)
Move : ROM free
• L/S at the right arm
Look : Swelling (+), deformity (+), excoriated wound (+), drop hand (-)
Feel : Pain (+), NVD : thumb tes (-)
Move : ROM Limited
L/S at abdominal region:
• I : Distention (-), multiple excoriated wound (+)
• A : Bowel sound (+) normal
• P : Pain (-), muscular rigidity (-)
• P : Tympani (+)
Secondary survey
Head
L/S at Head Region
Look : Lacerated wound (+) 6x1 cm at the parietal region already suture, swelling (+)
Feel : Pain (+), step off deformity (-)
L/S at the upper face
Look : symmetrically, Lacerated wound (+) 4x1 cm at the right frontal region, swelling (+)
Feel : Pain (+), step off deformity (-)
L/S at the middle face
Look : Symmetrically, wound (-) , swelling (-)
 Feel : Pain (+), step off deformity (-)
Visus & Eye Movement :
• 2/2
L/S at the lower face
Look : Swelling (-), excoriated wound (+) 3x2 cm at the right and left cheek region,
excoriated wound (+) 2x2 cm at the chin region, lacerated wound (+) 2x0,5 cm at the lower lips
Feel : Pain (+), step off deformity (-)
L/S Intra oral
• Maloclussion (-)
• Dental loss (+) at the right upper incisivus
• Lacerated wound 2x0,5 cm already suture
• Upper extremity
• L/S at the left arm
Look : Swelling (-), deformity (-), excoriated wound (+), lacerated wound (+) 4x1 cm was suture
Feel : Pain (+), NVD (-)
Move : ROM free
• L/S at the right arm
Look : Swelling (+), deformity (+), excoriated wound (+), drop hand (-)
Feel : Pain (+), NVD : thumb tes (-)
Move : ROM Limited
L/S at abdominal region:
• I : Distention (-), multiple excoriated wound (+)
• A : Bowel sound (+) normal
• P : Pain (-), muscular rigidity (-)
• P : Tympani (+)
Thorax  in normal limit
Lower extremity  in normal limit

Radiology Result
Head Schaedle AP/Lat
• There was no hematosinus
• There was no septal dasal deviation
• There was no discontuinity of bone
humerus Ap
• There was discontinuity of the right neck humerus
Head CT Scan :
• There was SCALP hematoma at the frontotemporoparietal dextra et sinistra region
• There was no discontinuity of bone
• There was no hyperdense area
• Sulcus & Gyrus was narrow
• System ventricle was narrow
• There was no midline shift
Assessment :
1. Close fracture neck at the right humerus
2. Lacerated wound at the parietal region
3. Lacerated wound at the right frontal region
4. Lacerated wound at the lower lips
5. Lacerated wound at the left arm
6. Multiple excoriated wound at the facial
7. Excoriated wound at the right and left arm
8. Excoriated wound at the abdomen

Management
• Inj. Cefazolin 1 gr
• Inj. Metamizole sodium 1 gr
• Laboratory examination

Laboratory result
• Hb : 10,5 gr/dL
• White blood count : 11,800/uL
• Platelet : 290.000 /uL
• Ht : 33 %
• Glucose ad random : 163 mg/dl
• CT :2
• BT :8

Diagnose :
1. Close fracture neck at the right humerus (ICD 10 CM S42.201A)
2. Lacerated wound at the parietal region (ICD 10 CM S20.56)
3. Lacerated wound at the right frontal region (ICD 10 CM S20.56)
4. Lacerated wound at the lower lips (ICD 10 CM S20.56)
 5. Lacerated wound at the left arm(ICD 10 CM S20.56)
6. Multiple excoriated wound at the facial (ICD 10 CM S51.812A)
7. Excoriated wound at the right and left arm (ICD 10 CM S51.812A)
8. Excoriated wound at the abdomen (ICD 10 CM S51.812A)

Consult to Neuro surgery division :

• Conservative neurology
Consult to orthopaedic surgery division :
• Hospitalize
• U Slab
• Orif elective
Consult to plastic surgery division :
• Wound care with supratule + Chloramfenicol zalf

Follow Up