M.

Ruth Pailah, P, 69th,

Primary Survey:
A: intubate --> clear
B: RR 12 x/mnt on ventilator SIMV peep 3 FiO2 60%, simetris (+), KG (-), sonor (+/+),
vesikuler (+/+) --> clear
C: TD : 107/59 mmHg Akral hangat (-), HR 64x/mnt teraba lemah, reguler, CRT < 2dtk -->
clear
D: GCS E1VtM2

Initial assessment: potential life threatening

Secondary Survey

A: tidak ada
M: Tidak diketahui nama obatnya
P: HT sekitar 10 tahun
L: tidak diketahui
E: tertabrak sepeda motor

KU : impaired consciousness

RPS :
6 hours the patient's SMRS had an accident, when the patient was guiding a bicycle and was
about to cross, the patient was hit by a motorcycle and then fell to the left. The mechanism
is not known for certain. After the incident the patient was still able to communicate after
that the patient was taken to PMI Hospital for initial treatment, from PMI the patient was
taken to PKU limiting, upon arrival at PKU limiting the patient vomited once, fainted (-),
dizzy (-), then performed a CT head scan and Chest X-ray, after 2 hours in GCS Hospital the
patient decreased to 11 and then became E1V1M1 and the patient was intubated with
fentanyl and ecron sedation. Then the patient is referred to RSS for further treatment.

Pemeriksaan fisik :
Ku lemah, E1VtM1
TD : 87/ 49 mmHg
N : 86 x/mnt
RR : 12 x/mnt on ventilator simv+ peep 3 FiO2 60

Kepala : CA (-/-), SI (-/-), pupil isokor (6mm/ 6mm), RC (-/-), RK (-/-), soft tisue swelling (-),
jejas (-)

Upper face
I : simetris (+), jejas(-), diploplia (-), gerakan bola mata sdn, telakantus (-), Vulnus excoriatum
(-), VL (-) , edema (-), deformitas (-)
P : sensoris sdn, NT (-), krepitasi (-)

Middle face
I : simetris (+), racoon eye (-) , telekantus (-) , diplopia(-) , gerakan bola mata (-) , epistaksis (-
), otorrhea (-) , battle sign (-), deviasi septum nasi (-), VE (-), VL(-) , step off (-)
P : sensoris sdn, floating maxilla (-), NT (-)

Lower face
I : simetris (+), avulsi dental (-) vulnus laceratum (-) , vulnus excoriatum (-), maloklusi (-),
false movement mandibula (-)
P : sensoris sdn, step off alveolar (-), NT (sdn), gliding mandibula - /-

Leher : pembesaran kgb (-)

Thorax :dbn
Abdomen : dbn
Ekstremitas: akral dingin, CRT < 2 detik

Assessment :
Slamet Riyanto, L, 59th,1901038

Primary Survey:
A: bicara jelas (+), snooring (-), gurgling (-)--> clear
B: RR 20 x/mnt , simetris (+), KG (-), sonor (+/+), vesikuler (+/+) --> clear
C: TD : 143/ 62 mmHg Akral hangat (+), HR 80 x/mnt teraba kuat, reguler, CRT < 2dtk -->
Clear
D: GCS E4V5M6

Initial assessment: no potential life threatening

Secondary Survey

A: tidak ada
M: tidak ada
P: tidak ada
L: jam 18:00
E: kecelakaan lalu lintas

KU : nyeri di wajah

RPS :
16 hours before entering the hospital the patient had an accident, the patient was hit from
behind by another motorist, the mechanism of the event was not known for sure because
the patient did not remember the incident. After the incident the patient was taken to the
Puskesmas display, then the patient was taken to PKU Bantul for further treatment. In PKU
Bantul, the patient is examined for CT scan, chest radiograph, wrist joint and nasal
examination. Complaints of vomiting (-), fainting (+) about 10 minutes, dizziness (+). Then
the patient is referred to RSS for further treatment. Upon entering the hospital, patients
complained of pain in the face, especially on the left.

Pemeriksaan fisik :
Ku: Sedang, E4V5M6
TD : 143/ 62 mmHg
N : 80 x/mnt
RR : 20 x/mnt
T : 36,6°C

Kepala : CA (-/-), SI (-/-), pupil isokor (3mm/ 3mm), RC (+/+), RK (+/+), soft tisue swelling (-),
jejas (-)

Upper face
I : simetris (+), jejas(+), tampak hematoma periorbita dextra, telakantus (-), Vulnus
excoriatum (-), VL (-) , edema (+), deformitas (-),
P : sensoris dbn, NT (-), krepitasi (-)

Middle face
I : simetris (+), racoon eye (-) jejas (-),hematoma palpebra bilateral (+) edema di regio
maxilla dextra (-), telekantus (-) , diplopia(-) , gerakan bola mata (dbn) , epistaksis (+/+),
otorrhea (-) , battle sign (-), deviasi septum nasi (-), VE (-), VL(-) , step off (-)
P : sensoris dbn, floating maxilla (+), NT (-)

Lower face
I : simetris (+), avulsi dental (-) vulnus laceratum (-) , vulnus excoriatum (-), maloklusi (-),
false movement mandibula (-)
P : sensoris dbn, step off alveolar (-), NT (-), gliding mandibula - /-

Leher : pembesaran kgb (-)

Thorax :
I : simetris (+/+), KG(-), jejas(-)
P : VF dbn
P : sonor +/+
A : ves +/+, wh - /-, rh - /-
Cor : S1-S2 tunggal, regular

Abdomen :
I : distensi (-),jejas (-)
A : BU + normal
P : timpani
P : NT (-), defans muscular (-)

Ekstremitas: akral dingin, CRT < 2 detik

Assessment :
- Cerebral concussion
- Fraktur zygomaticomaksilaris kompleks dekstra
- Fraktur lefort 1
- Fraktur os nasal
- Fraktur distal end radius dekstra et sinistra

Plan (usul) :
- Rawat inap
- Diet lunak
- IVFD NaCl 0.9% 20 tpm
- Inj. Ceftriaxon 1 gr/12 jam
- Inj. Ketorolac 30 mg/8 jam
- Inj. Ranitidin 50 mg/12 jam
- Pro Rekonstruksi of facial bone (elektif)
- Dari bedah saraf : rencana konservatif
- Dari orthopaedi : rencana short arm cast
Mustija, L, 49th 1901039

Primary survey :
ABC  clear

Secondary Survey:
A llergic : tidak ada
M edikasi : tidak ada
P ast Illnes : tidak ada
L ast Meal : makan malam pukul 19.00
E xposure : post jatuh dari sepeda

Initial Assesment : no life-threatening

KU: pain on the left lower leg

RPS:
± 6 hours the patient's SMRS climbs a cliff to install a water torn. Suddenly the ground that
the patient stepped on then the patient fell off a cliff (4m). when landing the patient stands
first, then rolls around. Patients went to the puskesmas for treatment, were directed to
Hardjolukito Hospital. Checked rö obtained:
- CF oblique 1/3 tibia dekstra complete
- CF oblique 1/3 proximal fibula dekstra complete
- CF lateral condylus tibia sinistra incomplete
Fainting (-), nausea / vomiting (-).
The patient was reffered to RSUP Dr. Sardjito for further treatment
RPD:
HT (-) DM (-) Jantung (-) Asma (-) Alergi (-)

Pemeriksaan Fisik
KU Sedang, E4V5M6
Vs on normal value

Kepala:
Pupil isokor 3mm/3mm (+/+), RC (+/+), RK (+/+), CA (-/-), SI (-/-), jejas (-)

Leher:
I: Jejas (-)
P: NT (-)

Thorax:
I: Simetris (+), ketinggalan gerak (-/-) jejas (-)
P: VF ka=ki, krepitasi (-), NT (-/-)
P: sonor/sonor
A: Vesikuler (+/+) Rh (-/-), Wh (-/-)

Abdomen:
I: Distensi (-) jejas (-)
A: BU (+) normal
P: Supel (+), NT(-), defans muskuler (-)
P: timpani (+)

Pelvis:
stabil (+) NT (-)

Ekstremitas:
Akral hangat, CRT < 2'', edem (-), jejas (-)

Status Lokalis genu sinistra

L: Tampak luka lecet(-), hematoma (+) anterior, Active bleeding (-) deformitas (+) edema (+)
F: krepitasi(-) Nt(+)
M: ROM terbatas karena nyeri

Status Lokalis cruris dekstra

L: Tampak luka lecet(-), hematoma (-) sirkuler, Active bleeding (-) deformitas (+) edema (-)
F: krepitasi(-) Nt(+)
M: ROM terbatas karena nyeri

Status lokalis cruris sinistra

L: Tampak luka lecet(-), hematoma (-) sirkuler, Active bleeding (-) deformitas (+) edema (-)
F: krepitasi(-) Nt(+)
M: ROM terbatas karena nyeri

Status lokalis ankle dekstra

L: Tampak luka lecet(-), hematoma (-) , Active bleeding (-) deformitas (+) edema (+)
F: krepitasi(-) Nt(+)
M: ROM terbatas karena nyeri

Assessment: (usul)
- CF oblique 1/3 tibia dekstra komplit
- CF oblique 1/3 proximal fibula dekstra complete
- CF condylus lateral tibia sinistra incomplete