XXX/M/23yo

Closed (R) Rami Pubic Superior Fracture

Closed (R) Subtrochanter Femur Fracture (AO Class 32-B3.1)
Open (R) Tibial Fibula Shaft Fracture Type II (AO Class 42-B2.3)
Diffuse Peritonitis due to Blunt Abdominal Injury

Debridement + Back slab (R) Leg

ICD 10 : S32.501A, S72.21XA, S82.202B, K65.9

ICD 9CM : 86.22, 93.5
 History
Chief complaint : deformity on his right thigh & wound on the right leg
It has been suffered since 10 hours before admitted to Haji Adam Malik
Hospital. History of MVA (+). Patient hit a car from the opposite
direction when riding a motorcycle. After accident, patient was brought
to district hospital (Langsa General Hospital), and was reffered to Haji
Adam Malik Hospital for futher treatment.
History of uncounsicousness : (-)
History of past illness & last medication : (-)
History of allergy of food and drugs : (-)
(R) Thigh :
L : deformity (+), swelling (+), haematome (+)
F : pain (+), NVD (+), pulsation artery dorsalis pedis and tibialis posterior was palpable, sensation (+) True Apparent Anatomical
Length Length Length
normal, SaO2 98-99% all toes
M : AROM hip joint (+) normal Right 78 90 41
AROM knee joint limited due to pain
AROM ankle joint (+) normal Left 82 94 45
(R) Leg :
L : deformity (+), swelling (+), lacerated wound on the anteromedial side, size 2x1cm, bone based, irregular edge
moderate contamination True Apparent Anatomica
F : pain (+), NVD (+), pulsation artery dorsalis pedis and tibialis posterior was palpable, sensation (+) normal, SaO2 98- Length Length l
99% all toes Length
M : AROM hip joint (+) normal
AROM knee joint limited due to pain Right 78 90 41
AROM ankle joint limited due to pain
Left 82 94 45
Diagnose :
Closed (R) Rami Pubic Superior Fracture
Closed (R) Subtrochanter Femur Fracture (AO Class 32-B3.1)
Open (R) Tibial Fibula Shaft Fracture Type II (AO Class 42-B2.3)
Diffuse Peritonitis due to Blunt Abdominal Injury

Treatment in Emergency room :

Antibiotic Inj.
Analgetic Inj.
Antitetanus Inj.
Debridement + Back slab (R) Leg
Laparotomy Exploration Digestive Department
caudal
caudal