Mr. A., 33 y.o.

R
 LABORATORY FINDING

Hemoglobin 11.5
Hematocryte 34
WBC 27.600
Platelets 438.000
Lactate 92.0
Creatinine 30.7
Albumin 3.8
SGOT 72
SGPT 24
Ureum 28
Blood Sugar 180
Sodium 136
Potassium 3.3
 BLOOD GAS ANALYSES

pH 7.362
PCO2 47.6
PO2 93.2
HCO3 26.4
Base Excess 0.9
O2 Saturation 96.7
TCO2 51.8
 Working Diagnosis
Mild head injury with skull base fracture middle
fossa
Lacerated wound at right frontal
Lung contusion at right hemithorax
Closed fracture at right clavicle middle third
comminutive displaced Allman classification
Group 1
Lacerated wound at right middle finger dorsal
aspect
Lacerated wound at right knee joint
 Management
Analgetic, antibiotic, tetanus prophylactic
Oxygenation
Thorax Surgery Department:
Performed:
Closed observation with serial x-ray
Neurosurgery Department:
Conservative treatment
Wound cleansing and suturing
Plastic Surgery Department:
Conservative treatment
 Orthopaedics and Traumatology Department:
Performed:
Wound cleansing and suturing for lacerated wound
Immobilization with arm sling for clavicle fracture
Plan to:
ORIF with plate and screw for clavicle electively
Thank You