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Departement of Surgery
Thursday April 24th 2014
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Name : Mr. M
Age : 23 y.o
Sex : Male Address : Babat, Lamongan
Date : Wednesday, April 23th 2!"
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ANAMNESIS #hie$ %omplaint
&ost tra'% a%%ident
&resent illness
&atient %ame post tra'% a%%ident 3,( ho)rs be$ore
admission. *e got a ride on motor%y%le and he
%r)shed by %ar $rom his right dire%tion. *e
bo)n%ing )ntil thro)gh the %ar and $all in le$t side.A$ter
a%%ident he $aint and +omit 3 times. he %olor
o$ his +omit in reddish li-e blood, bron and
bla%-ish. No he $eel heada%he and di//y
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*istory illness
DM0. *0. Alergy0
1amily illness :0
So%ial history :
%igarrette 4Al-ohol0
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Airay and spine %ontrol : %lear 4, snorring0, gargling 0,
potensial obstr)%tion 0
Breathing : spontan, simetri% 4, 55
2x6min)tes, +es6+es, rh060, h060 #ir%)lation : &5
78x6min)tes, a%ral arm dry
red, #5 9 2, B& !2(6;2mm*g, Sp2 distal88D: (6!
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CT Scan
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Rontgen Thorax
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Assesment
Mild brain in)ry
M)ltiple )ln)s abrasio
#lose $ra%t)re os. /ygoma sinistra
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F1D Assering !( %%62" ho)rs
Fn.Metami/ole 3x( mg
Fn. #e$triaxon 2x!gr Fn.5anitidine 2x( mg
#6Sp.BS and Sp B G0L
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S)be%ti+e %omplaint
ital sign
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>xplain to the patient?s $amily abo)tthe diagnosis, etiology,
inter+entiono$ therapy, %ompli%ation, and
prognosis.
>xplain to the the patient?s $amilythat e o)ld do operation
to the
patient so the patient %animmobili/ed and red)%e the pain.
