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

22.55 wita
 Anamnesis (23.00)
Chief complain : Injury on the right cruris region
History Taking
 Suffered since 5 hours because of a traffic accident
 Mechanism of trauma :
 The patient is riding a motorcyle with moderate speed,
wearing helmet. Suddenly hit by transport car with high
speed from the opposite direction, then the patient's right
foot hit the car bumper. Other trauma mechanism is
unknown
 Anamnesis (23.00)
 There was previous treatment situational sutured at the
hospital Bhayangkata before come to RS Bahtramas
 There was no unconssiusnes
 There was no history of alcohol or drugs consumption
 There was no history of HT and DM
 Physical examination (23.00)

 Generalized state:
Moderate illness, composmentis, good nourish
 Vital sign:
 Blood pressure : 140/90 mmHg
 Heart rate : 70x/m, regular, strong
 Respiratory rate : 20x/m, spontaneus, symmetric,
regular, thoracoabdominal type
 Temperature : 36,5 celcius degree/axillary
 VAS 6/10
 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 (23.05)

SECONDARY SURVEY
 Right Cruris Region
LOCALIZE STATE (23.10)

I : Deformity (-), swelling (+) Wound (+) 6cmx4cm, 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 :
23.15 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

17/9/2019
01.00 wita
 DIAGNOSIS

Open fracture Os Fibula Dextra

DIFFERENTIAL DIAGNOSIS :
Fracture os tibia
Neurovascular Injury
 PHARMACOLOGY

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

Consult Orthopedic
Surgeon

MANAGEMENT