4032016-Mr. P- 20 years old-Chest Pain caused by chest blunt trauma + First Rib Fracture - dr....
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Transcript of 4032016-Mr. P- 20 years old-Chest Pain caused by chest blunt trauma + First Rib Fracture - dr....
IDENTITY
Name : Mr. PAge : 20 years oldAdress : Morame VillageAdmission : March, 4th 2016DPJP : dr. Syamsul Rijal, Sp.B
HISTORY TAKING• Chief complain : Chest Pain• Anamnesis : Suffered since 11 hours before admitted to the hospital due to traffic accident. Mechanism of trauma Patient as a rider of motorcycle at slippery road. When Suddenly The Patient lose his balanced and thrown from his motorcycle. The patient didn’t use helmet. Patient in alcohol consume. History of unconsciousness unknown. There was no history of nausea, and vomit.
ClearARR 20x/min regular, spontaneous
thoracoabdominal type, symmetricalBBP 120/80 mmHg
Pulse = 84x/min, regular, strongC GCS 15 (E4V5M6), pupil isochors,
Ø : 3mm/3mm, light reflex +/+ DT = 37,00 C (axillary) E
Primary survey
Head: No abnormalitiesFace : No abnormalitiesEyes : No abnormalitiesNose : Bleeding (-)Mouth : No abnormalitiesEars : No abnormalitiesNeck : No AbnormalitiesChest : No abnormalitiesAbd : No abnormalities
secondary survey
Thorax I : Symmetrical left and right, there is no retractionP : No crackles, no tendernessP : Resonant in both hemithorax A : Vesicular, no additional sound