Trauma : 2
Non trauma : -
PRIMARY SURVEY
Airway : Clear
Breathing :
Insp : symmetrical movement of chest wall, bruise (-),
RR : 39x/mins
Pal : VF right = left, crepitation (-),
pain on palpation (-)
Per : sonor right = left, pain on percussion (+/-)
Aus : vesicular basic breath sound, wh -/-, rh-/-
PRIMARY SURVEY
Chief complain
: dispnoe
Additional complain : pain in right regio of
thorax
History of Illness :
Patient came to UKI hospital with dispnoe.
The patient got an acident 3 days ago n was
treated in jt.negara premier hospital. The patient
was in motorcycle accident becouse he wasnt
saw the hole in the street. The patient wear full
helmet and was 60km/h in speed.
SECONDARY SURVEY
HEAD TO TOE
General Examination
Head : Bruise (-) , edema (-) tumor (-), wound (+) :
regio peri oral
Eyes : Round shaped pupil, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect Light
Reflex +/+, CA-/-, SI-/Neck : Bruise (-), hematoma (-), no palpable
enlargement on regional lymph nodes
Thorax
Insp : Symmetrical movement of chest wall,
bruise (+)
Pal : VF right = left, crepitation (-),
pain on palpation (+)
Per : sonor right = left, percussion pain (+/-)
Aus : vesicular basic breath sound, wh -/-, rh-/-
Abdomen
Insp : flat, hematoma (-), bruise (-),
muscular defense (-), scars (+)
Palp : smooth, no palpable enlargement on
hepar and spleen
Perc : Tympani, pain on percussion (-)
Ausc : bowel sound (+) 4x/min
Extremities
cap. refill < 2, warm extremity, edema (-),
bruise (+) regio superior extemitas,
hematoma (-)
AMPLE
Allergy
: Medication : Past Illness : thorax traumatic history,
hipertension, laparotomi e.c apendicity
Last Meal
: 1.pm
Event
: Had motorcyles accident
Nose
Ear
Mouth
Anus
OUE
X-ray
DIAGNOSIS
TREATMENT
Non Medikamentosa
- hospitalize
- Wound toilet
- IVL
Medications:
- kotorolac
- Ikaneuron
- Ergotika
- Terpasef
PRIMARY SURVEY
Airway : Clear
Breathing :
Insp : symmetrical movement of chest wall,
bruise (-),
RR : 20x /mins
Pal : VF right = left, crepitation (-),
pain on palpation (-)
Per : sonor right = left, pain on percussion (-/-)
Aus : vesicular basic breath sound, wh -/-, rh-/-
PRIMARY SURVEY
C = Warm extremities, Pulse = 82x/min ,
History of Illness
Patient came to UKI after got a motorcycle
accident 15 minutes before. The patient use
helm, unfortunately got crashed with the car
behind his motorcycle and then he dropped to
the street. His head was still with the helm.
He drove the motorcycle 80 km/hours. There
was wound at his feet, hands, and knee.
Patient also felt the pain after accident.
SECONDARY SURVEY
HEAD TO TOE
General Examination
Head : Bruise (-) , edema (-) tumor (-), wound (-)
Eyes : Round shaped pupil, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect Light
Reflex +/+, CA-/-, SI-/Neck : Bruise (-), hematoma (-), no palpable
enlargement on regional lymph nodes
SECONDARY SURVEY
Thorax
Insp : Symmetrical movement of chest wall,
bruise (-)
Pal : VF right = left, crepitation (-),
pain on palpation (-)
Per : sonor right = left, percussion pain (-/-)
Aus : vesicular basic breath sound, wh -/-, rh-/-
Abdomen
Insp : flat, hematoma (-), bruise (-),
muscular defence (-), scars (-)
Palp : smooth, no palpable enlargement on hepar
and spleen
Perc : Tympani, pain on percussion (-)
Ausc : bowel sound (+) 7x /min
Extremities
1. Regio cubiti dextra :
L : wound (+), dirty, basic : subcutis
F : crepitation (-), pain in palpation (+)
M : limited in motion