Ms. Megawati Close Fracture at the Right Leg
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Transcript of Ms. Megawati Close Fracture at the Right Leg
IDENTITYName : Ms. M
Age : 21 years old
Address : Konsel
Admission : November 5th, 2015 at .00
DPJP : dr. Tri Tuti Hendarwati, Sp.OT
HISTORY TAKINGChief Complain : pain at right leg
- Anamnesis : suffered since ±4 hours before admitted to the hospital due to traffic accident.
- Mechanism of trauma : The patient was driving a motorcycle when suddenly hit by a car from the right side.
- No history of unconscious, no history of nausea and vomit.
PRIMARY SURVEY
PatentARR 20x/min regular, spontaneous
thoracoabdominal type, symmetrical BBP 100/70 mmHg
HR = 86 x/min regular, strongC GCS 15 (E4V5M6), pupil isochors,
Ø : 2.5 mm/2.5 mm, light reflex +/+ DT = 36,80 C (axillary) E
Right leg region:I : Deformity (+), swelling (+), hematoma (+), wound (-)
P : Tenderness (+)
ROM : Active and passive movement of the knee and ankle joints are limited due to pain
NVD : Sensibility is good, pulsation of the dorsalis pedis arteries is palpable. Capillary refill time < 2”
SECONDARY SURVEY
DIAGNOSIS clinic Closed fracture at the right lower limb
RADIOLOGICAL FINDINGS
Rigth Cruris X-Ray
AP / Lateral View
DIAGNOSIS RADIOLOGIC Closed comminutive fracture 1/3 middle right tibia
MANAGEMENT IVFD RL Analgesic Antibiotic Consult ortopedi
THANK YOU