Identitas

• Name : Mr. S
• Age : 53 years old
• Adress : Baruga
• Occupation : Enterprenuer
• Admission : January 14th 2019
• Doctor in charge : dr.Tri Tuty H, Sp.OT
Primary Survey (13.22)
A
Clear, cervical spine control

RR 20x/min regular, spontaneous B

thoracoabdominal type, symmetrical

C
BP = 130/80 mmHg
Pulse = 88x/min, regular, strong

D
GCS 15 (E4M6V5), isochor pupil, Ø 2,5mm/2,5mm, light reflex (+/+)

E
T = 36.80 C (axillary)
History Taking (13.26)
Chief Complaint : Pain at right leg

Anamnesis: The patient admitted to hospital with complain of pain at right leg
since 1 hour ago after an trafic accident

Mechanism of trauma :
Patient was rode a motorcycle at moderate speed and used helmet. Suddenly, patient
was hit from behind with a car at high speed and he fell to left side of the road. Other
mechanism was unknown

There was no history of syncope, nausea, and vomiting

There was no history of alcohol and drug consumption
There was no history of previous treatment
 General state: Moderate illness, composmentis, well-nourished

• Head : within normal limit

Vital sign:
BP : 120/80 mmHg • Face : within normal limit
HR : 88x/min, regular, • Eyes : within normal limit
strong • Nose : within normal limit
RR : 20x/min, regular, • Mouth : within normal limit
symmetrical • Neck : within normal limit
T : 36,5/axillary • Chest : within normal limit
VAS : 7 • Abdomen : within normal limit
• Upper Extremity: within normal limit
• Lower Extremity: Localized
Localized state
Right lower extremity
- Inspection : Deformity (+), swelling (+), bleeding (+) active, lacerated
wound at regio cruris with size 3x2x0,2 cm and multiple excoriated
wound at regio pedis.
-Palpation : tenderness (+)
- ROM : active and passive movement at ankle joint limited due to pain.
-NVD : Sensibility was good, pulsation at dorsalis pedis artery was
palpable, capillary refill time <2 seconds.
Cliical finding
Planning
-Blood routine
-Plain photo right pedis ap/oblique
RADIOLOGY
 Open fracture
oblique 1/3
Diagnose distal right
fibula

DD: 1. Dislocation of right ankle joint

2. muscle contusion of right pedis
 MANAGEMENT
Pharmacological Non-Pharmacological
 IVFD • Immobilisation
 anti bleeding • Elevastion
 Antibiotics • Rest
 analgesics
 H2RA

Consult to orthopaedic surgeon