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    15-10-2019, Mr. Jamal, 50 Yo, V.Laceratum Cruris Dextra + Skin Loss + Fraktur Os Fibula, Dr. Moh. Rizal Alizi, M.Kes, Sp. OT-1

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    Mr. J, a 50-year-old male driver, was admitted to the hospital after a motorcycle accident. He suffered an open fracture of his right fibula bone. Physical examination found a 6cm x 4cm wound on his right lower leg with tenderness and limited range of motion of the knee. X-rays confirmed the open fibula fracture. He received IV fluids, antibiotics, analgesics, and PPI. His wound was cared for and the leg immobilized. An orthopedic surgeon consultation was planned.

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    15-10-2019, Mr. Jamal, 50 Yo, V.Laceratum Cruris Dextra + Skin Loss + Fraktur Os Fibula, Dr. Moh. Rizal Alizi, M.Kes, Sp. OT-1

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    anon_893244902
    37 views15 pages
    Mr. J, a 50-year-old male driver, was admitted to the hospital after a motorcycle accident. He suffered an open fracture of his right fibula bone. Physical examination found a 6cm x 4cm wound on his right lower leg with tenderness and limited range of motion of the knee. X-rays confirmed the open fibula fracture. He received IV fluids, antibiotics, analgesics, and PPI. His wound was cared for and the leg immobilized. An orthopedic surgeon consultation was planned.

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    KOAS BEDAH

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    15-10-2019, Mr. Jamal, 50 yo, V.Laceratum Cruris Dextra + Skin loss + Fraktur Os Fibula , dr. Moh. Rizal Alizi, M.Kes, Sp. OT-1

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    Mr. J, a 50-year-old male driver, was admitted to the hospital after a motorcycle accident. He suffered an open fracture of his right fibula bone. Physical examination found a 6cm x 4cm wound on his right lower leg with tenderness and limited range of motion of the knee. X-rays confirmed the open fibula fracture. He received IV fluids, antibiotics, analgesics, and PPI. His wound was cared for and the leg immobilized. An orthopedic surgeon consultation was planned.

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    Download as PPTX, PDF, TXT or read online from Scribd
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    37 views15 pages

    15-10-2019, Mr. Jamal, 50 Yo, V.Laceratum Cruris Dextra + Skin Loss + Fraktur Os Fibula, Dr. Moh. Rizal Alizi, M.Kes, Sp. OT-1

    Uploaded by

    anon_893244902
    Mr. J, a 50-year-old male driver, was admitted to the hospital after a motorcycle accident. He suffered an open fracture of his right fibula bone. Physical examination found a 6cm x 4cm wound on his right lower leg with tenderness and limited range of motion of the knee. X-rays confirmed the open fibula fracture. He received IV fluids, antibiotics, analgesics, and PPI. His wound was cared for and the leg immobilized. An orthopedic surgeon consultation was planned.

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    of 15

    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

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