Professional Documents
Culture Documents
October 19th, 2013 EMERGENCY ROOM WAHIDIN SUDIROHUSODO GENERAL HOSPITAL MAKASSAR
ZT
IDENTITY
Name Age Admission : AF : 14 years old / Male : October 20th, 2013 at 00.00
AUTOANAMNESIS
(at 00.04)
Suffered since 3 hours before admited to Wahidin General Hospital due to traffic accident. The patient riding a motorcycle and suddenly got a crash with a car from the left side. The patient fall to ther right side History of unconsciousness (-), vomit (-), nausea (-)
PRIMARY SURVEY
(at 00.10)
A B C
D
E
: patent : RR = 20 x/min, symmetric, spontaneous, thoracoabdominal type : BP = 110/80 mmHg, HR = 88 x/min, regular, strong : GCS 10 (E2M5V3), light reflex +/+, pupil isochors, d = 2,5 mm/ 2,5 mm : T = 37,4oC (Axillary)
SECONDARY SURVEY
(at 00.12)
Right Thigh Region I : Wound (-). Deformity (+), swelling (+), hematoma (+). P : Tenderness (+) ROM : Active and passive movement of knee joint are limited due to pain Active and passive movement of hip joint are limited due to pain NVD : Pulsation of the dorsalis pedis artery palpable. Tibialis posterior palpable Capillary refilling time < 2, extend big toe (+)
LABORATORY FINDINGS
(00.28)
13.8 g/dL 38.7 g/dL 12.300 g/dL 345.000 g/dL 730 300 (-)
RADIOLOGY FINDINGS
(00.30)
CT SCAN
Normal
DIAGNOSIS
Moderate head injury GCS 10 Closed fracture proximal third of right femur,
MANAGEMENT