Duty Report

(12th Dec 2019)

Wan Nor Syazana

Nur Hayani
 Dokter Jaga Patient
Trauma = 1 patient
dr.Sri Non-Trauma = 0 patient
Admitted = 1 patient

Name Age Diagnosis

Mrs. YM 75 y/o Closed dislocation of articulatio genu
sinistra.
1st case
Identity & History

Name Mrs. YM Past Medical History:

Sex Female (-)
Age 75 y/o

Family History:
(-)
Other complaints:
Chief complaint:
Difficulty in moving left leg due to
Pain at the left leg 2 hours
pain
before admitted
 HISTORY OF PRESENT ILLNESS

Two hours before admitted, the patient was walking by the road on her way home
with his sister when suddenly she tripped and fell to the ground. She fell on her
left side and could not move her left leg. She was brought to the hospital
immediately. Due to the incident, there’s closed dislocation of articulatio genu
sinistra. ROM is limited due to pain.
 Biomechanism of Trauma

20:00 pm
18:00 pm
IGD
(before
RSUD
admitted)
IGD Koja

Patient was immediately

brought to RSUD Koja.
Patient complaints
The patient was walking pain on left leg.
by the road on her way
home when suddenly she
tripped and fell to the
ground. She fell on her
left side and could not
move her left leg.
 Primary Survey

Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), warm extremities, BP: 134/60, HR: 89 x/mins, Temp: 36.3 C, CRT <2 sec
Disability :
GCS (E4M6V5) = 15
Secondary Survey

●Head : bleeding (-), swelling (-), tenderness (-), hematoma (-)

●Eyes : eyebrow (-), isokor 3mm/3mm, CA (-/-), SI (-/-)
●Nose : hair nose (-), bleeding (-)
●Ear : normotia, bleeding (-)
●Mouth : mucosa redness, cyanosis (-)
●Neck : enlargement of lymph nodes (-)
Thorax :
• Inspection : Symmetrical
• Palpation : Vocal fremitus & tactile symmetrical
• Percussion : resonance in both lungs
• Auscultation : Vesicular, Rh -/-, Wh -/-; Heart sound I-II normal

Abdomen :
• Inspection : Flat, mass (-),
• Auscultation : Peristaltic sound (+), normoperistaltic
• Palpation : Soft & non tender, distention (-)
• Percussion : Tymphany
Local state of genu sinistra

• Look: deformity (+), oedem (+)

• Feel: tenderness (+) pulsation a.

poplitea (+), a. dorsalis pedis (+), a.
tibialis posterior (+), normal distal
sensory, CRT <2s, SpO2 (98%).
Warm extremities.

• Move: Limited ROM of left leg due

to pain. Limited extension, flexion,
adduction and abduction.
Diagnosis and problem

Problems:
Working diagnosis:
Closed dislocation of articulatio • Pain
genu sinistra. • Limited ROM of left leg
Management

SURGERY NON SURGERY

Consult an orthopedic Pharmacology

Omeprazole inj 2x1g

Ketorolac inj 3x30mg
Ringer Laktat

Non-pharmacology

Bed rest
Immobilization