DEPARTEMENT OF SURGERY

20 th december 2014DEPARTEMENT OF SURGERYName: Mrs. Siti muanikAge: 28th y.oSex: femaleAddress: lamongan Date examination: 19th des, 2014

anamnesisChief complaint Left shoulder painMOIPatient came with left shoulder pain post traffic accidents. Patient was riding a motorcycle, helmet +, sudden loss of balance when going to deflect her motorcycle.Then, she fell to the position of the left shoulder hit the asphalt and she felt there was a " kretekk " in his left shoulder that time. unconscious-, PTA -, vomiting -, nausea -, headache -, abdominal pain -, bloody rhinorea bloody othorrea -, short of breathing -

3Vital sign :BP: 129/53P: 90RR: 20xT: 36

Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (-). C-spine normal Breathing : spontan, simetric (+), RR 20x/minutes, ves/ves, rh-/-, wh-/-, Sp02 100% with O2 supportCirculation : PR 90x/minutes, acral warm dry red, CRT < 2, BP 129/53 mmhgDisability : GCS 456, LP +/+, isocor pupil 3mm/3mm, lateralisasi-Exposure : temp 36CSecondary surveyHead and neck : anemic (-), icteric (-), cyanosis (-), dyspneu (-), scalp hematom (-), vulnus (-)Thorax : simetric (-), retraction (-), lesion (-)Pulmo : ves/ves, rh-/-, wh-/-Cor : S1S2 single, murmur (-), gallop (-)Abdomen : lesion (-), flat, distended (-), tympani (+), liver and spleen were not palpable, bowel sound (+), pelvic stable, pain (-)Extremities : acral warm, dry, red, CRT< 2

Status localizedEt regio shoulder sinistra :L : soft tissue swelling +, skin intact +, deformity +F : painful +, distal arterial pulsation +, krepitasi +, sensibility +M : ROM limited due to pain, abnormal movements -Clue and cue :Female, 28 yoPost traffict accidentLeft shoulder painKrepitasi +GCS : 456thorax

asessmentClose fracture clavicula 1/3 medial displace

therapy IVFD assering 1500 cc/24 jamRemopain 3x30 mg ivAcran 2x1 amp ivC/ Sp.OT pro ORIF

Vital signGCSsign of increased pressure intracranial

Explain to the patients family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.