M I S T

: falling out of the motorcycle : active bleeding on head : pain on injury : wound toilet

Airway : Clear Breathing Insp : chest wall movement symmetrical, RR 20x/min, bruise (-) Pal : crepitation Per : sonor symmetrical Aus : Basic breath sound vesiculer, rhonki -/-, wheezing -/Clear

Circulation Warm acral, pulse: 92 x/min, blood pressure: 140/80 mmHg, c.r <2 Clear Disability GCS E4M6V5, pupil isochoric 3/3 mm, centered, direct light reflex/indirect light reflex +/+ , lateralization (-) Clear Exposure Theres no life threatening wound

 Chief

complain Active bleeding on head of illness (allo anamnesis)

History

Patient came with an open wound on the beack of head an hour ago. Initially the patient suddenly fell down from the motorcycle because the patient was drunk. Patients head hit the wall. And then, the patient was brought by his friends to the clinic and just cleaned the wound. Patiens are advised by the clinic to go to the nearest emergency room. Vomiting (-) ,nausea (-) , headache (-) , fainting (-), amnesia (-), deformity (), fever (-).

Allergy Medication Past Illness Last Meal admittance Event

:::: 4 hours before

: falling out of motorcycle

HEAD TO TOE
Head

: normocephali, bruise (-) open wound (+) Eyes : Conjungtiva anemis -/-, sclera icteric -/-.

Thorax Insp : movement of chest wall symmetrical. Pal : vocal fremitus right = left Per : sonor right = left Aus : Basic breath sound vesiculer, Rh -/-, Wh -/-

Abdomen

Ins : flat Pal : Palpable, tenderness (-) Per : tympani

 Ekstremitas

Warm acral, crt < 2, odema

Localize state L: open wound injury. 6x2x0.5 cm. Active bleeding (+) F: pain (+) M: normal

Vulnus Laseratum Regio Ocypital

 Verban

4 inch

Mm

: As.Mefenamat 2x500 mg Cefixime 2x200 mg

M I S T

: falling out of the motorcycle : Pain on right shoulder : Pain on injury : -

Airway : Clear Breathing Insp : chest wall movement symmetrical, RR 20x/min, bruise (-) Pal : crepitation Per : sonor symmetrical Aus : Basic breath sound vesiculer, rhonki -/-, wheezing -/Clear

Circulation Warm acral, pulse: 92 x/min, blood pressure: 140/80 mmHg, c.r <2 Clear Disability GCS E4M6V5, pupil isochoric 3/3 mm, centered, direct light reflex/indirect light reflex +/+ , lateralization (-) Clear Exposure Theres no life threatening wound

 Chief

complain Pain on right shoulder of illness (auto anamnesis)

History

patient came to the hospital with pain on the right shoulder since one hour ago. Initially, patient got crush accident then he fell down, his right shoulder collided with the first position, as a pedestal. The pain feels like tingling, constantly, getting sick when moving, pain persist even after changing position. Patient not taking any medication. Loss of consciousness (-) fainting (-) nausea (-) vomitting (-) amnesia (-) head injury (-) collision abdomen (-) chest collision

Allergy Medication Past Illness Last Meal admittance Event

:::: 8 hours before

: falling out of motorcycle

HEAD TO TOE
Head Eyes

: normocephali, bruise (-) : Conjungtiva anemis -/-, sclera

icteric -/-.

Thorax Insp : movement of chest wall symmetrical. Pal : vocal fremitus right = left Per : sonor right = left Aus : Basic breath sound vesiculer, Rh -/-, Wh -/-

Abdomen

Ins Pal Per Aus

: flat : Palpable, tenderness (-) : tympani : bowel sound (+) 6x/min

 Ekstremitas

Warm acral, crt < 2, odema Pain on right shoulder (+) Localize state L: bruise (-) wound (-) redness (-) F: pain (+) M:

Closed fracture clavicula 2/4 medial dextra without NVD disorder

Abdomen Ins : flat Pal : Palpable, tenderness (-) Per : tympani Aus : bowel sound (+) 11x/min Extremity : warm acral, cap. refill < 2

Fr.Calvicula sinistra

 Kettese

3x1 Ranitidine 2 x 1 tab

Terima

kasih