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Patient List

No Identity Admission Diagnosis Treatment


to E.R.
2. Mr. Minan April 6th Closed Fracture of Left Patella VS Obs
Transverse Displaced IVFD RL
Tanusaputra/ 2015 at
Inj analgesic
15.15
75yo/1-14 - WITA
Immobilization
64-17
Consult to
Orthopaedi Surgeon:
Posterior Splint
Hospitalized
Pro ORIF

A L R CT ECG
2. Mr. Minan Tanusaputra/ 75yo/1-14 -64-17
April 6th 2015 at 15.15 WITA
Chief Complain :
Unable to move left knee
History :
2 hours before admission patient was involved in a fight
at his residence around Veteran. The patient got shoved
and fell on his knees. Later he felt immense pain and
unable to move his left knee. The patient got no other
injury on his body. He was brought to massage parlor
before went to Ulin Hospital.

L R CT ECG
Primary Survey
Clear, snoring (-), gurgling (-), C-spine
A
control (-)

Clear, RR= 18 tpm, symmetric respiratory


B
movement, VBS

C Blood Pressure: 130/80 mmHg


Pulse rate : 98 bpm, reguler, strong lifted

GCS E4V5M6 (15), Round and


D symmetric pupils diameter (3mm/3m),
Light reflexes (+/+)

A L R CT ECG
A -

M -

P -

3 hours before
L admission
At his residence
E around Veteran

A L R CT ECG
Secondary survey
Head : Normocephaly
Eye : Anemic conj. (-/-), icteric sclera (-/-),
Head/Neck Mouth : Moist mucous membrane
Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

I : symmetric respiratory movement, retraction (-),


wound (-)
Chest P : symmetric VF
P :sonor
A : VBS, Rh (-/-), Wh (-/-)

I : Wound (-), distension (-), hematoma (-)


A : Normal bowel sound
Abdomen P : H/L/M not palpable, tenderness (-), rebound
tenderness (-), muscular defense (-)
P : Tympanic in all quadrants

Extremities Warm extremities, parese (-), edema (-)

A L R CT ECG
Clinical Pictures

A L R CT ECG
Local Status

a/r Left knee :


L: Deformity (+) Swelling (+)
Open wound (-)
F: Tenderness (+) CRT < 2
M: ROM limited due to pain

A L R CT ECG
Post installment of Posterior Splint
Laboratory Result April 6 th 2015
Items Result Normal Value Unit

Hemoglobine 12,0 14.00 - 18.00 g/dl

Leukocyte 14,0 4.0 10.5 thousand/ul

Eritrocyte 3,75 4.00 5.50 million/ul

Hematocrit 35,3 32.00 44.00 Vol%

Thrombocyte 201 150 450 Ribu/ul

RDW-CV 13,2 11.5 14.7 %

MCV 94,2 80.0 97.0 Fl

MCH 32,0 27.0 32.0 Pg

MCHC 33,9 32.0 38.0 %

A R CT ECG
Items Result Normal Value Unit

Gran% 72,1 50.0-70.0 %

Lymphosite% 15,6 25.0-40.0 %

MID% 12,3 4.00-11.00 million/ul

Gran# 10,10 2.50-7.00 Billion/ul

Limfosit # 2,2 1.25-4.0 Billion/ul

MID# 1,7 Billion/ul

A R CT ECG
Items Result Normal Value Unit
GDS 114 <200 Mg/dL

PT 10,0 9,9-13,5 Second

APTT 24,4 22,2-37,0 Second

INR 0,89

SGOT 44 0-46 U/l

SGPT 28 0-45 U/l

Ureum 31 10-50 mg/dL

Creatinin 1,1 0,7-1,4 mg/dL

Natrium 142,0 135-146 mmol/L

Kalium 3,8 3,4-5,4 mmol/L

Chloride 105,8 95-100 mmol/L

A R CT ECG
Left Knee X-ray April 6th 2015

A L CT ECG
Working Diagnosis
Closed Fracture of Left Patella Transverse
Displaced

A L R CT ECG
Management
VS Obs
IVFD RL
Inj analgesic
Immobilization
Consult to Orthopaedi Surgeon:
Posterior Splint
Hospitalized
Pro ORIF

A L R CT ECG