Case Report

Monday , January 25th 2016

Team on duty :
Dr.Joko Siswanto ( Jaga 1 )
Dr.Haji Ifradin Pinim ( Jaga 2 )
Dr.Mohan siddiq ( Jaga 3 )
Dr.Raja M Purba ( jaga 3 )
Dr. M Reza ( Jaga 4 )
Dr. Reza F ( jaga 4 )
Dr.Ahmad Muhtadi ( Jaga 5 )
Dr.Iskandar ( Jaga 6 )

Patient Identity
Name : Muliadi
Age : 27 years old
Sex : Male
Address : Neuhen, Kajhu, Aceh Besar
MR : 1-07 86 79
HP : 085358322195
Admission time : 11.30 PM

Time Response

Chief Complaint
Pain and difficukt to move the right ankle
Present illness history
The patient came to Zainoel Abidin emergency room with a chief complain
unable to move the right ankle since 1 hour ago. Previously the patient was
repairing a machine but his ankle was cut. History of unconsciousness (-)

Physical Examination
Primary Survey :
A : Clear
B : Spontan, RR: 20 breaths/ minute
C : Pulse: 90 beats/minute
D : GCS: 15 (E4 M6 V5)

L/S at the right ankle region

L : Lacerated wound (+) 7x3x3 cm
 plantar flexion (-), bone exposed (-), tendon exposed (+)
F : Pain (+), NVD (-) discontinuity of bone (-), thomson test (+)
M: ROM limited at the right ankle

Secondary survey
Head in normal limit
Neck in normal limit
Thorax in normal limit
Upper extremity in normal limit
Lower extremity
L/S at the right ankle region
L : Lacerated wound (+) 7x3x3 cm
plantar flexion (-), bone exposed (-), tendon exposed (+)
F : Pain (+), NVD (-) discontinuity of bone (-),
Thomson test (+)
M : ROM limited at the right ankle
Vas : 5

Assessment
Total rupture achilles tendon of the right ankle

Management
Stop oral intake
IVFD RL 0,9% 20 drips/min
Cefazoline inj 1 g
Ketorolac inj 30 mg
Tetagam 250 IU
Laboratory examination
Radiology Examination

Laboratory result
Hemoglobin : 12,6 gr/dl
White Blood Count : 19,300/ul
Platelets : 234.000/ul
Hematocrit : 34 %
CT/BT : 7/2

Diagnose
Total rupture achilles tendon of the right ankle
(ICD X CM S86.001 )

Consult to Orthopedic division

Debridement emergency
Repair tendon

Operation report :
Performed debridement with normal saline, povidonie iodine and peroxide
Identify the achilles tendiny - there was Total rupture achilles tendiny
Performed repair tendon achilles with non absorbable 1.0 suture with Krachow
technique
Perfomed foreslab at the right ankle

Post operative diagnosed

Total rupture Achilles tendon of the right ankle
(ICD X CM S86.001

Follow Up