Patient List

No Identity Admission to ER Diagnosis Treatment

3. Mr. Syamsuri/ Male/ 51 May 18th 2019 at Open Right Ankle Injury Treatment from ER
Yo/ MR 14288678 10.40 PM Lauge Hansen • Wound toilet
Classification Pronation • IVFD NS 20 tpm
• Inj. Ceftriaxone 1 gr
Abduction Stage III
• Inj. Asam Tranexamat 1 amp
• Inj. Ketorolac 30 mg
• Inj. Ranitidin 50 mg

Co to Orthopedic surgery
• Pro Debridement + OREF cito
 3. Mr. Syamsuri/ Male/ 51 Yo/ MR 14288678
Admitted May 18th 2019 at 10.40 PM

Chief Complain : Pain in the right ankle

History taking :
The patient was brought because he complained of right ankle pain after the
patient had an accident at 8:00 a.m. The patient got on a motorcycle hit by a truck in
the hole. The patient was hit from the right by the truck when he wanted to turn to the
gas station. After that the patient falls and the patient's right leg is crushed by the
motor. After the event, the bone appears from the patient's skin and there is bleeding.
The patient also has difficulty moving his finger. After that the patient was immediately
taken to Pelaihari Hospital and immediately referred to Ulin Hospital due to the absence
of ortopaedic. Vomiting (-) headache (-) decreased consciousness (-) blurred vision (-)

History of Past Illness : ORIF due to closed fracture of left humerus 5 months ago
Primary Survey
• Airway :
• Snoring (-), gurgling (-), with C-spine control
• Breathing :
• Lesion (-), symmetrical movement, RR : 18x/minute (regular), vesicular breath
sound at whole region. SpO2 : 99% with O2 supply 3 lpm
• Circulation :
• HR : 98x/minute (regular, strong pulse), BP : 130/80 mmHg, warm extremities,
active bleeding (-)
• Disability :
• GCS E4V5M6, pupil equal 3 mm/3 mm, light reflex (+), lateralization (-)
Secondary Survey
A -

M -

P -

L 05.00 AM

E Liang Anggang Road

 • Head : Pale conjunctiva (-/-), sclera icteric (-/-), swelling (-)
• Nose / Ear : Bloody rhinorrhoea (-/-), Bloody ottorrhoea (-/-)
Head • Mouth : Moist mucous membrane
• Neck : enlargement of the lymph node (-)

• I : Symmetric, retraction (-)

Chest • P : Sonor (+/+)
• A : vesiculer (+/+) no ronchi , no wheezing

• I : distension (-), lesion (-)

Abdomen • A : Bowel sound (+)
• P : Muscular defans (-), tenderness (-)
• P : timpani(+), shifting dullness (-)

Extremities • warm extremities (+/+), look local state

 Localize State a/r right ankle joint
• Look : deformities (+) bone expose
in distal third cruris (+), vulnus (+)
laceratum in dorsal pedis with size
9x3x1 cm base muscle, VL ar
malleolus medial (+) size 6x4x1 cm
base bone.
• Feel : tenderness (+), a. dorsalis
pedis (++), a. tibialis posterior (hte)
• Move :
• Passive Flexion movement of
ankle joint 0 degree
• passive Extension movement of
ankle joint 0 degree
Clinical Picture
Clinical Picture
Cruris X-Ray AP/Lateral
Ankle joint Xray
Thorax xray
 Laboratory Finding 18th May 2019
Examination Result Normal Value
Hemoglobin 12,6 12,00-16,00 g/dl
Leukosit 10,6 4,0-10,5 ribu/ul
Eritrosit 4,04 3,90-5,50 juta/ul
Hematokrit 35,5 37,00-47,00 vol%
Trombosit 243 150-450 ribu/ul
RDW-CV 13,4 11,5-14,7 %
MCV 87,9 80,0-97,0 fl
MCH 31,2 27,0-32,0 pg
MCHC 35,5 32,0- 38,0 %
Gran% 62,2 50 – 81
Limfosit% 24,5 20 – 40
MID % 13,3
Gran# 6,60 2,5 – 7
Limfosit# 2,60 1,25 – 4
 Laboratory Finding
Examination
Examination Result
Result Normal Value
Normal Value

Hasil
RandomPTBlood Glucose 302
9,3 9,9-13,5 detik
<200.00 mg/dl
SGOT
INR 26
0,86 5-34- u/l
SGPT
Control Normal PT 18
10,8 0-55- u/l
Ureum 112 10-50 mg/dl
Hasil APTT 19,0 22,2-37,0 detik
Creatinin 7,13 0.6-1.2 mg/dl
Control Normal APTT 24,8 -
Natrium 141 135-146 mmol/L
Random Blood Glucose 113 <200.00 mg/dl
Kalium 2,9 3,4-5,4 mmol/l
SGOT 42 5-34 u/l
Chlorida 102 95-100 mmol/l
SGPT 64 0-55 u/l
Ureum 19 10-50 mg/dl
Creatinin 1,00 0.6-1.2 mg/dl
Natrium 144 135-146 mmol/L
Kalium 3,7 3,4-5,4 mmol/l
Chlorida 106 95-100 mmol/l
 Diagnosis

Open Right Ankle Injury Lauge Hansen Classification

Pronation Abduction Stage III
 Management
Treatment from ER Co to Orthopedic surgery
• Wound toilet
• IVFD NS 20 tpm • Pro Debridement + OREF cito
• Inj. Ceftriaxone 1 gr
• Inj. Asam Tranexamat 1 amp
• Inj. Ketorolac 30 mg
• Inj. Ranitidin 50 mg
Intra Operation
Post Operation