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Tn. A ( 23 YO)
M : Hit by motorcycle I : Regio frontalis sinistra, regio manus dextra , regio dorsal palmaris dextra S : Pain, active bleeding (-) T : car
Primary Survey
Airway : Clear Breathing : Insp: bruise (-), chest wall movement symmetrical, RR 18 x/ min, hematoma (-) Pal: crepitation sub cutis (-) Per : sonor right = left Aus : Basic breath sound vesicular
C = warm extremities, Pulse = 78bpm, capillary refill time <2 D = GCS E4M6V5, pupil isochors 3mm/3mm, centered, direct light reflex/ indirect light reflex +/+ E = there is no life threatening wound
History of illness :
Patients present with complaints of pain in head and the left leg and right hand fingers. 1 hours ago patients experienced motorcycle accident on the way from Kali Malang . When the patient was hit by a motorcycle on the street and thrown. Patient wearing a helmet half face and fell while the patient is still unconscious, but when you want to stand the patient feel pain. And then patient taken to hospital in . In hospital, patient only in a cast and rontgen. And then the patient was refferred to RS UKI.
SECONDARY SURVEY
HEAD TO TOE
Eyes: pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+ Ear: Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-) Thorax: Insp : bruise (-), movement of chest wall symmetrical Pal : crepitation (-), tenderness (-) Per : sonor right = left Aus: Basic breath sound vesicular
HEAD TO TOE
Eyes: pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+ Ear: Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-) Thorax: Insp : bruise (-), movement of chest wall symmetrical Pal : crepitation (-), tenderness (-) Per : sonor right = left Aus: Basic breath sound vesicular
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Abdomen: Ins: flat, bruise (-) Aus: bowel sound (+) 8x/min Pal: Supel, tenderness (-), muscular defense (-) Per: tympani
Extremity:
Status localized : Regio cruris dextra I : sinus +, pus +, blood -, edem P: Pain + pallor puffiness pulselessness poikilothermy paratesia + paralysis ROM hip joint : Flexi > 120 Extensi 0 abduksi 40 adduksi 30 internal rotasi 40 eksternal rotasi 40 ROM regio genu Flexi > 120 Extensi 0 internal rotasi 40 eksternal rotasi 40
TREATMENT
Hospitalized Wound toilet Mm Ketorolac ( analgesik). Kaltrofen supp
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