SHORT

CASE
TRAUMA
 Name : Mr. J
Age : 50 years old
Sex : Male
Address : Jalan Palapa
Occupation : Driver
Admission : October, 16th 2019 (22.55)
Doctor in Charge : dr. Moh Riza Alizi, M.Kes, Sp.OT

IDENTITY
 A Clear, Cervical Spine Control

B Respiratory rate 20x/m, spontaneous, thoracoabdominal type,

symetric

C Blood Pressure 140/90 mmHg

Pulse 70x/m, regular, strong

D Glasgow Coma Scale (E4M6V5), Isochoric

pupil, Light reflex +/+

PRIMARY
SURVEY E Temperature 36,5OC/Axillary
VAS 6/10

22.55 wita
 Anamnesis (23.00)
Chief complain : Injury on the right cruris region
History Taking
 Suffered since 6 pm because of a traffic accident
 Mechanism of trauma :
 crashing into a car while driving a motorcycle, because of avoiding
public transport car on the right, then the patient was shocked because
there was a car that stopped on the left, the patient hit the car from the
back then fell, the patient's right foot hit the car bumper and then taken
to the hospital Bhayangkara, the patient is then sutured situationally
and must be referred because of swelling. Other trauma mechanism is
unknown
 Anamnesis (23.00)
 There was no history of syncope, nausea and vomiting
 There was no history of drugs or alcohol consumption
 There was no history of nose, mouth and ear bleeding
 There was previous treatment situational sutured
SECONDARY SURVEY (23.05)

GENERAL STATE
Compos mentis, moderate illnes,
good nourish
 Head : Within Normal Limit Neck : Within Normal Limit
Face : Within Normal Limit Chest : Within Normal Limit
Eyes : Within Normal Limit Abdomen : Within Normal Limit
Nose : Within Normal Limit Upper limb : Within Normal Limit
Mouth : Within Normal Limit Lower limb : Localized state
Ears : Within Normal Limit

LOCAL STATE (23.10)

SECONDARY SURVEY
Right Cruris Region
LOCALIZE STATE (23.15)

I : Deformity (-), swelling (+) Wound (+) Hematoma (-)

P : Tenderness (+)

ROM : Active and Passive movement

knee joint limited due to pain

NVD : Sensibility was good, dorsalis

pedis artery pulsation (+) Capillary refill
time <2 second
Planning Diagnostic :
23.45 WITA

Routine Blood
X-Ray right Cruris AP/Lat
 Routine Blood

PARAMETER RESULT REFERENCE VALUE

WBC 11,27 x 103/Ul 4,00 – 10,00

RBC 4,59 x 106/uL 4,00 – 6,00
HGB 12,3/dL 12,0 – 16,0
HCT 37,2% 37,0 – 48,0

17/9/2019
00.15 wita
X-Ray Right Cruris AP/Lat
 DIAGNOSIS

Vulnus Laceratum Cruris Dextra+ Skin Loss +

fracture Os Fibula Dextra

DIFFERENTIAL DIAGNOSIS :
Fracture os tibia
 PHARMACOLOGY

Non Pharmacology
 IVFD
• Rest
 Antibiotic
• Wound Care
 Analgetic •Imobilisai
 PPI • Eduksi

Consult Orthopedic
Surgeon

MANAGEMENT