STATUS PASIEN ORTHOPAEDI

IDENTITY
NAME : Munasipah
AGE : 44 years old
NO. MR : 490558
ADDRESS : Pemalang, Jawa Tengah

CHIPS OF COMPLAIN : Pain in the left leg

MECHANISM OF INJURY :
approximately 12 before admission patient experience traffic accident while riding a mo
crashed into a car that came in the opposite direction and fell to the right. The patient us
(-), vomiting (-), fainting (-). Then the patient was taken to Kajen Regional Hospital and h
examination, laboratory, iv line, spalk application. Due to limited facilities, patient was re
Hospital

CAR ACCIDENT :
MOTORCYCLE : √
BICYCLE :
WALK :
HOME :
INDUSTRY :

PHYSICAL EXAMINATION :
AIR WAY : Patient can speak clearly, snoring (-), gargling (-) --> Airway Clear
RR:20x/minute, symetric in static and dinamic,adequate depth and breath, retractio
BREATHING : breathing

HR: 81x/minute, reguler, adequate depth and volume, Blood Pressure:110/60mmHg,

CIRCULATION : cyanosis (-) --> Stabil Circulation
DISABILITY : isocoric round pupil, diameter 3mm, Light Reflex +/+
GCS : E4M6V5

LOCAL STATUS : Left leg

LOOK : spalk applied (+), deformity (-), shortening (-), multiple injury (+), situational suture (+)

FEEL : tenderness (+), swelling (-), a. dorsalis pedis pulsation (+), crepitation (did no
MOVE : limited ROM due to pain

KLINICAL PICHERS (PHOTO:

LATERAL

:
POSTERIOR (IF POSIBLE) :
ANTERIOR

:
MEDIAL :
RONTGEN (AP / LAT )

:
SPECIFIC (IF NEEDED) :
THORAX PA

:
ECG (>30 YO)
: -
LAB : Hb, L, Tr, CT, BT / PTT, APTT, HBsAg, + Blood Sugar (>30 YO)

Hb: 5.9 g/dl

L: 6.74 x 10^3/ul
Tr: 150.000 /mm3
CT: 3'00"
BT: 4'30"
HBsAg (-)
Blood Sugar: 142
WORK DIAGNOSTIC : Open fracture of supracondylair and intracondylair of the right femur grade IIIA
Open fracture middle third of the right tibia displaced communitive grade II
Open fracture middle third of the right fibula displaced oblique grade II
Closed fracture of the right maleolus lateralis displaced oblique

Infus RL 20 drops per minute

Infus NaCl drip crom 20 drops per minute

Infus HES 20 drops per minute

Stabilize leg with spalk
INITIAL PLAN / Tx :
US PASIEN ORTHOPAEDI

Munasipah
44 years old
490558
Pemalang, Jawa Tengah

Pain in the left leg

admission patient experience traffic accident while riding a motorcycle. The patient
me in the opposite direction and fell to the right. The patient used a helmet. Nausea
-). Then the patient was taken to Kajen Regional Hospital and had radiological
v line, spalk application. Due to limited facilities, patient was referred to Kraton

ient can speak clearly, snoring (-), gargling (-) --> Airway Clear
etric in static and dinamic,adequate depth and breath, retraction (-) --> Adequate
breathing

er, adequate depth and volume, Blood Pressure:110/60mmHg, cold extremity (-),
cyanosis (-) --> Stabil Circulation
isocoric round pupil, diameter 3mm, Light Reflex +/+
E4M6V5

Left leg
ty (-), shortening (-), multiple injury (+), situational suture (+)

, swelling (-), a. dorsalis pedis pulsation (+), crepitation (did not perform)
limited ROM due to pain
 -
r (>30 YO)
ndylair and intracondylair of the right femur grade IIIA
d of the right tibia displaced communitive grade II
d of the right fibula displaced oblique grade II
t maleolus lateralis displaced oblique

Infus RL 20 drops per minute

Infus NaCl drip crom 20 drops per minute

Infus HES 20 drops per minute

Stabilize leg with spalk