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Social history: smoking (+) 1 pack a day, patient denies drinking alcohol when using a motorbike
History of illness: Uncontrol High blood pressure (+) Diabetes mellitus (-)
Primary Survey
• Airway :
• Snoring (-), gurgling (-), stridor (-), without C-spine control
• Breathing :
• Lesion (-), symmetrical movement, RR : 20x/minute (regular), vesicular breath
sound at whole region, sonor percussion at whole region. SpO2 : 99% without
O2 supply
• Circulation :
• HR : 123x/minute (fast,weak pulse), BP : 90/50 mmHg, warm extremities,
active bleeding (+)
• Disability :
• GCS E4V5M6, pupil equal 3 mm/3 mm, light reflex (+), lateralization (-)
Secondary Survey
A -
M -
P -
L 12.00 am
E Jl. Basirih
• Head : Pale conjunctiva (-/-), sclera icteric (-/-), edem palpebral (+/+), hematoma
palpebral (+/+)
Head • Nose / Ear : Bloody rhinorrhoea (-/-), Bloody ottorrhoea (-/-)
• Neck : enlargement of the lymph node (-), swelling (-)
Look :
• deformity (+) at 1/3 distal femur, swelling (+), hematom
(-) laserasi (-)
Feel :
• tenderness (+), a. femoralis (++) a. iliaca superficial
(++).
Move :
- Limited movement of flexion hip joint and knee due to
pain
Clinical Pictures
Thorax X-ray 7/4/2019
Pelvic X-ray
(7/4/2019)
Femur X-ray
7/4/2019
Laboratory Finding March , 22nd 2019
Result Normal Value
Hemoglobin 13.9 12,00-16,00 g/dl
Leukosit 27.8 4,0-10,5 ribu/ul
Eritrosit 4.50 3,90-5,50 juta/ul
Hematokrit 38.7 37,00-47,00 vol%
Trombosit 398 150-450 ribu/ul
RDW-CV 12.9 11,5-14,7 %
MCV 86 80,0-97,0 fl
MCH 30.9 27,0-32,0 pg
32,0- 38,0 %
MCHC 35.9