Scribd Logo
Upload

Welcome to Scribd!

  • 27 views

    Blunt Chest Trauma

    Uploaded by

    QueenIchma Chualunaeoneloph
    1) Mr. S, a 54-year-old man, was admitted to the hospital with pain in his chest after being involved in a traffic accident where the car he was in slammed into a guardrail. 2) Upon examination, he was found to have fractures of ribs VI and VII on his chest with bruising, a laceration on his forehead, and an abrasion on his left forearm. 3) Diagnostic tests including bloodwork, chest x-rays, and a head CT showed the rib fractures and no other major injuries. He was diagnosed with rib fractures, a forehead laceration, and a forearm abrasion and treated with IV fluids, pain medication, wound care, and consultation

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Blunt Chest Trauma

    Uploaded by

    QueenIchma Chualunaeoneloph
    27 views15 pages
    1) Mr. S, a 54-year-old man, was admitted to the hospital with pain in his chest after being involved in a traffic accident where the car he was in slammed into a guardrail. 2) Upon examination, he was found to have fractures of ribs VI and VII on his chest with bruising, a laceration on his forehead, and an abrasion on his left forearm. 3) Diagnostic tests including bloodwork, chest x-rays, and a head CT showed the rib fractures and no other major injuries. He was diagnosed with rib fractures, a forehead laceration, and a forearm abrasion and treated with IV fluids, pain medication, wound care, and consultation

    Original Description:

    Q

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1) Mr. S, a 54-year-old man, was admitted to the hospital with pain in his chest after being involved in a traffic accident where the car he was in slammed into a guardrail. 2) Upon examination, he was found to have fractures of ribs VI and VII on his chest with bruising, a laceration on his forehead, and an abrasion on his left forearm. 3) Diagnostic tests including bloodwork, chest x-rays, and a head CT showed the rib fractures and no other major injuries. He was diagnosed with rib fractures, a forehead laceration, and a forearm abrasion and treated with IV fluids, pain medication, wound care, and consultation

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    27 views15 pages

    Blunt Chest Trauma

    Uploaded by

    QueenIchma Chualunaeoneloph
    1) Mr. S, a 54-year-old man, was admitted to the hospital with pain in his chest after being involved in a traffic accident where the car he was in slammed into a guardrail. 2) Upon examination, he was found to have fractures of ribs VI and VII on his chest with bruising, a laceration on his forehead, and an abrasion on his left forearm. 3) Diagnostic tests including bloodwork, chest x-rays, and a head CT showed the rib fractures and no other major injuries. He was diagnosed with rib fractures, a forehead laceration, and a forearm abrasion and treated with IV fluids, pain medication, wound care, and consultation

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 15

    MORNING

    REPORT
    Fracture Costae VI, VII +
    Vulnus Escoriatum at Left
    Forearm + Vulnus Laceratum
    at Frontal region
    IDENTITY

    Name : Mr. S
    Age : 54 years old
    Admission : April, 20th 2018
    Doctor In Charge : dr. Syamsul Rijal , Sp.B
    TAKING

    Chief complain: Pain at the chest


    Anamnesis
    The patient come to hospital with pain in the chest. Suffered since 11 hours ago after got traffic
    accident
    Mecanism of trauma
    ○ The patient was slept in a car driven by his son. The patient sit beside driver’s seat and didn’t
    use seat belt. Suddenly the car crashed into guardrail and the patient slammed out of the car
    through the windshield and fell on the road. When he fell patient said his chest was bumped
    into something
    History of Trauma
    ○ There was no history of syncope,
    ○ There was no history of nausea and vomit
    ○ There was no history bleeding from nose, mouth, ears
    ○ There was no history of alcohol consumption
    ○ There was no history of previous medication
    Primary survey

    A Clear, O2 Via mask 8 lpm

    RR 36x/min, spontaneous,
    Symmetrical, Subcostal Retraction B
    C BP : 110/70 mmhg, HR = 82x/min, regular, strong

    GCS 15 (E4M6V5), pupil isochors, D


    E T = 36.40 C (axillary)
    Secondary Survey

    General status : moderate illnes, composmentis


    Head : Status Localis
    Eyes : Within Normal Limit
    Nose : Within Normal Limit
    Mouth : Within Normal Limit
    Neck : Within Normal Limit
    Chest : Status Localis
    Stomach : Within Normal Limit
    Upper and lower limb : Within Normal Limit
    Clinical finding
    Secondary Survey

    Localized State
    Frontal:
    I : Deformity (+), Hematoma (-), Wound (+) Vulnus
    laseratum post hecting, Swelling (-)
    P : tenderness (+)
    Secondary Survey

    Localized State
    Chest :
    I : Deformity (+), Hematoma (+) 3x 7 cm, Wound
    (-/-), Swelling (-/-)
    P : tenderness (+/+), crepitation (-/-)
    P : Sonor (+/+)
    A : Bronchovesiculer (+/+), Extrasound (+/+)
    Secondary Survey

    Localized State
    Antebrachium :
    I : Deformity (+), Hematoma (-), Wound (+) Vulnus
    escoriatum with size 1x7 cm, Swelling (-)
    P : tenderness (+), crepitation (-)
    Plan of Diagnostic

    ○ Rountine Blood
    ○ Chemistry Blood Test
    ○ Thorax X-Ray PA
    LABORATORIUM FINDING

    Rontin Blood 20/4/2018

    Parameter result Unit Referenc


    Chemistry Blood Test 20/4/2018
    e value
    WBC 34,93 10^3/uL 4.00-10.0 Parameter result Unit Referenc
    0 e value
    HGB 13,0 g/dL 12-16 GDS 366 Mg/dl 70-180

    PLT 273 10^3/uL 150-400


    Thorax and Skull X-Ray
    Diagnosis

    Fracture Costae VI, VII + Vulnus


    Escoriatum at Left Forearm + Vulnus
    Laceratum at Frontal region
    MANAGEMENT
    ○ IVFD
    ○ Analgetics
    ○ H2RA
    ○ Wound care
    Consult to general surgery
    Thank You

    You might also like