Admission
No Identity/Age Diagnose Treatment
to ER
1. Mr. Irhamnoor/24 7 th April Close fracture midle IVFD Rl 2000cc
th/1-42-48-80 2019, third right femur IVFD Hes 500cc
Admission tranverse displace + prc 2 Kolf
at 18.30 Open book fracture Inj ketorolac
pm + shock hemoragic Inj tetagram
with transient Inj ranitidin
respons
Co to orthopaedi
Pro ORIF elective
1. Mr. irhamnor/ 24 th/Admitted at
April, 7th 2019 at 18.30 pm/ 1-42-48-80
Chief Complain : pain at right waist and tigh
History taking :
Patients come with pain in the right thigh and waist. Patients claimed to have had a traffic
accident because of high speed and colliding with other motorists facing each other. Patients claim to use
a helmet. nausea / vomiting (- / -) amnesia (-), the patient is not aware after the event. blurred vision (-).
Patient claimed he had difficulty moving his legs, numb feet (-).
Social history: smoking (+) 1 pack a day, patient denies drinking alcohol when using a motorbike
History of illness: Uncontrol High blood pressure (+) Diabetes mellitus (-)
Primary Survey
• Airway :
• Snoring (-), gurgling (-), stridor (-), without C-spine control
• Breathing :
• Lesion (-), symmetrical movement, RR : 20x/minute (regular), vesicular breath
sound at whole region, sonor percussion at whole region. SpO2 : 99% without
O2 supply
• Circulation :
• HR : 123x/minute (fast,weak pulse), BP : 90/50 mmHg, warm extremities,
active bleeding (+)
• Disability :
• GCS E4V5M6, pupil equal 3 mm/3 mm, light reflex (+), lateralization (-)
Secondary Survey
A -
M -
P -
L 12.00 am
E Jl. Basirih
• Head : Pale conjunctiva (-/-), sclera icteric (-/-), edem palpebral (+/+), hematoma
palpebral (+/+)
Head • Nose / Ear : Bloody rhinorrhoea (-/-), Bloody ottorrhoea (-/-)
• Neck : enlargement of the lymph node (-), swelling (-)
• I : Symmetric, retraction (-), lesion (-)
Chest • Per : Sonor at whole region
• A : vesiculer breath sound, no ronchi , no wheezing
• I : distension (-), lesion (-)
Abdomen • A : bowel sound (+) 7-8x/minute
• P : soft, muscular defans (-), tenderness (-), liver and spleen not palpable
• P : tympani
• warm extremities (+/+), vulnus laseratum at manus sinistra, vulnus eksoriatum at
Extremities brachii and ante brachii sinistra, vulnus laseratum at pedis dekstra (+) active
bleeding (+)
Localize State a/r femur (Dx)
Look :
• deformity (+) at 1/3 distal femur, swelling (+), hematom
(-) laserasi (-)
Feel :
• tenderness (+), a. femoralis (++) a. iliaca superficial
(++).
Move :
- Limited movement of flexion hip joint and knee due to
pain
Clinical Pictures
Thorax X-ray 7/4/2019
Pelvic X-ray
(7/4/2019)
Femur X-ray
7/4/2019
Laboratory Finding March , 22nd 2019
Result Normal Value
Hemoglobin 13.9 12,00-16,00 g/dl
Leukosit 27.8 4,0-10,5 ribu/ul
Eritrosit 4.50 3,90-5,50 juta/ul
Hematokrit 38.7 37,00-47,00 vol%
Trombosit 398 150-450 ribu/ul
RDW-CV 12.9 11,5-14,7 %
MCV 86 80,0-97,0 fl
MCH 30.9 27,0-32,0 pg
32,0- 38,0 %
MCHC 35.9
PT 10.0 9,9-13,5 detik
INR 0.93
APTT 19.4 22,2-37,0 detik
Laboratory Finding March, 22nd 2019
Result Normal Value
GDS 241 <200 Mg/dl
SGOT 117 5 – 34 U/L
SGPT 98 0 – 55 U/L
Ureum 18 0 – 50 mg/dL
Kreatinin 1.29 0.72 – 1.25 mg/dL
Natrium 140 136-145
Kalium 2.9 3.5-5.1
Chlorida 107 98-107
Diagnosis
• Close fracture midle third right femur tranverse displace
• Open book fracture + shock hemoragic with transient response
Management
• Ivfd nacl 0.9% • Co to Orthopedic surgery
• Inj ketorolac - Debridement
• Inj tetagram - Pro ORIF clavicula
• x-ray pedis dekstra
• X-ray Wrist joint sinistra
• X-ray thorax
• Humers sinistra
