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

Working Diagnosis

Chest Pain caused by chest blunt

Trauma

MANAGEMENT

• IVFD• Analgesic• Antibiotic

• Consult surgeon

RADIOLOGICAL FINDINGS

• Chest x-ray• AP/lateral

view

Clinial Diagnosis

Chest Pain caused by chest blunt

trauma + First Rib Fracture

L/O/G/O

Thank You

BAGIAN ILMU BEDAHAndi Suci Kumala Sari