CASE REPORT

Wednesday, November 25th 2015

Team on duty
dr. M. Nazir Tambunan
(Jaga 1)
dr. Aa Ahmad
(Jaga 2)
dr. Mohan Siddiq
(Jaga 3)
dr. Sumrahadi
(Jaga 3)
dr. Kas Mulyadi
(Jaga 4)
dr. Herdi Gunanta S
(Jaga 5)
dr. M. Taqwa
(Jaga 5)
dr. Aulia Rahman
(Jaga 6)

Patient identity
Name
Age
Sex
Address
MR
HP
Driving licence
Admission time

: Cut Afrina Rahmi

: 16 years old
: Female
: Kuta Blang, Bireun
: 107-23-84
: 085371687001
: (-)
: at.11.58 PM

Date/h Examinati Laboratory

Radiology
Hour of Date/ho DPJP
our
on hour
Examination Examination Diagno ur
patien
stics
patient
t came
out
Sen Result Send Result
to ER
from ER
d
25-11
2015
06.55
PM

07.15 PM

07.00 08.30
PM
PM

08.30 09.00 11.15

PM
PM
PM

26-112015
18.00
PM
OK

dr.
Zukarnain
i, SpOT

Chief complaint
Pain and difficult to move of the right shoulder
Patient illnes History
Patient was referred from Meuraxa district hospital to RSUDZA
emergency room with a chief complain Pain and difficult to move of the right
shoulder for 8 hours. Innitially, She was riding motorcycle without helmet and
suddenly strucked by a truck from oppsite. She fell to the asphalt. History of
vomiting (-). History of decrease of counsciuosness (-)
.

Physical examination
A : Clear
B : Spontaneous, RR: 22 breaths/ minute
C : Blood pressure : 105/77 mmHg ,Pulse 64 beats/minute
D : GCS: 15 (E4M6V5) , isochoric pupil, light reflex
(+/+)no
lateralization
S/L : at the right shoulder :
L : wound lacerated size 3x2cm, deformity (+)
F : pain (+)
R : limited
Secondary survey
Head and neck
in normal limit
Thorax

S/L : at the right shoulder :

L : wound lacerated size 3x2cm. deformity (+)
F : pain (+)
R : limited
Abdominal in normal limit
Pelvic region in normal limit
Upper Extrmity
in normal limit
Lower Extrmity
in normal limit

VAS : 4
Assessment:
Open fracture of the right clavicle

Management

Stop oral intake

Head up 30
O2 4 L/minutes via canule
IVFD NaCl 20 drips/minute
Inj. Cefazoline 1 gram
Inj. Ketorolac 30 mg
Laboratory examination

Laboratory result
Hb
: 12,2 gr/dl
White blood count
: 14.400 /ul
Platelet
: 272.000 /ul
Ht
: 38 %
Blood glucose adrandom : 114 mg/dl
Radiology result
Thorax Ap
right clavicle

: there was fracture of the middle third of the

Diagnose
Open fracture of the midle third of the right clavicle (ICD 10 CM S42.0)
Consult to orthopedic division
Performed debridement emergency + ORIF
there was no BOR Performed debridement
Operative Report :
At the right shoulder
Performed debridement with H202 3% + povidone iodine + Nacl 0,9%
Wound operation close by primary sutured
Post Op Diagnose
Close fracture of the midle third of the right clavicle (ICD 10 CM S42.0)

Follow Up

Date

27/11/
2015
POD I

Pain(+) General Condition

good
BP : 130/70 mmhg
HR : 86x/minutes
RR : 20x/minutes

A
:

PostIVFD
RL
debridement
gtt/minute
Close fractureInj. Cefazoline
of the midle third ofgr/12 hours
the right clavicle
Inj . Ketorolac
mg/ 8 hours
Inj. Gentamicyn
L/S
at
the
right
mg/ 8 hours
shoulder
Inj. Ranitidine
L : wound close by
mg/ 12 hours
gauze dry
Planning :
F : pain (+)
ORIF elective
M : ROM limited at the
left leg

20
1
30
80
50