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    LAPORAN KASUS 19/10/2015 Trauma Orthopedi: Puspita Widyasari Favi Rani P. Ananda R. Mariska Maria

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    Puspita Widyasari
    This document summarizes a medical case report from October 19, 2015. It describes a 55-year-old female patient who was injured in a pedestrian accident with a motorcycle, suffering an open fracture to her right lower leg. Upon examination and testing, she was found to have open fractures of the right tibia and fibula. Her treatment plan included debridement, splinting, and planned surgery to repair the fractures.

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    LAPORAN KASUS 19/10/2015 Trauma Orthopedi: Puspita Widyasari Favi Rani P. Ananda R. Mariska Maria

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    Puspita Widyasari
    17 views16 pages
    This document summarizes a medical case report from October 19, 2015. It describes a 55-year-old female patient who was injured in a pedestrian accident with a motorcycle, suffering an open fracture to her right lower leg. Upon examination and testing, she was found to have open fractures of the right tibia and fibula. Her treatment plan included debridement, splinting, and planned surgery to repair the fractures.

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    orto

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    ortho

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    This document summarizes a medical case report from October 19, 2015. It describes a 55-year-old female patient who was injured in a pedestrian accident with a motorcycle, suffering an open fracture to her right lower leg. Upon examination and testing, she was found to have open fractures of the right tibia and fibula. Her treatment plan included debridement, splinting, and planned surgery to repair the fractures.

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    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    17 views16 pages

    LAPORAN KASUS 19/10/2015 Trauma Orthopedi: Puspita Widyasari Favi Rani P. Ananda R. Mariska Maria

    Uploaded by

    Puspita Widyasari
    This document summarizes a medical case report from October 19, 2015. It describes a 55-year-old female patient who was injured in a pedestrian accident with a motorcycle, suffering an open fracture to her right lower leg. Upon examination and testing, she was found to have open fractures of the right tibia and fibula. Her treatment plan included debridement, splinting, and planned surgery to repair the fractures.

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    © All Rights Reserved
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    LAPORAN KASUS 19/10/2015

    Trauma Orthopedi
    Puspita Widyasari
    Favi Rani P.
    Ananda R.
    Mariska
    Maria
    Patient Identity
    • Name : Mrs. N
    • Gender : woman
    • Age : 55 y.o.
    • No. RM : 11258959
    • Address : Ds Tlogo Waru RT 5/3 Malang
    • Marital Status : Married
    • Hospitalized : 19/10/2015
    Primary Survey
    • Airway: Patent
    • Breathing: Spontaneous breath, simetris, RR:
    20x/minutes
    • Circulation: BP 150/80 mmHg, CRT <2 sec, HR
    100x/minutes, akral hangat
    • Dissability: alert, GCS 456
    Secondary Survey
    • Anamnesis :
    Chief complain:
    Right lower leg pain

    History of present illness:


    Patient come to the ER with open wound in thw right lower leg and
    feel pain after accident.
    Shourtness of breath (-), decrease of consciousness (-) convulsions
    (-)

    • Past medical history :


    DM (-) HT (+) uncontrolled

    • Family history:
    DM (-) HT (+)
    • Medical history:
    (-)

    • History of allergy :
    (-)

    • MOI:
    Pedestrian accidents with motorcycles
    Objective
    Physical Examination
    Generalis Status
    General state GCS 456
    Vital Sign BP 150/80, HR 100 x/minutes , RR 20x/minutes, Tax 36, 8 C
    Head/Neck conjungtiva anemis (-), sclera icterus (-), pupil isokor,
    enlarged lymph nodes (-)
    Thorax Pulmo : vesikuler, simetris, Rhonki - - , Wh - -
    -- --
    -- --
    Cardio : S1 S2 normal, murmur (-), gallop (-)

    Abdomen Flat, soefl, bowel sound (+) normal, abdominal pain (-), no
    palpabe liver lien enlarged
    Ekstremity Edema (+), CRT < 2 detik
    Local status

    Look (L) Open wound in the R/ tibia dextra 1/3 medial


    grade II, swelling (+)

    Feel (F) Tenderness (+), AVN distal (+)

    Move (M) ROM limited pain


    Working diagnose
    • Open wound tibia dextra 1/3 medial
    • Open wound fibula dextra
    Planning Diagnose
    • X-ray cruris dextra AP/Lateral
    • Lab lengkap : DL, FH, SE
    Laboratory Result
    • Lab :
    – DL : 11,50/4,10/1448000
    – OT/PT: 20/14
    – Ur/Cr: 33,20/0,50
    – SE : 134/3,61/107
    – FH : dalam batas normal
    Radiology
    Clinical
    picture
    Final Diagnose
    • Open fracture tibia dextra 1/3 medial grade II
    • Open fracture fibula dextra segmental
    Planning therapy
    • Debridement
    • Backslab
    • ORIF planned

    Medikamentosa :
    • Cefazolin 1 gr IV
    • Ketorolac 10 mg IV
    • Ranitidin 50 mg IV
    • Tetagam 250 mg IV
    TERIMA KASIH

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