Mr. Rusdianto/ 41 y.o.

/1-42-33-17
/Admitted at 00.30 am 23nd March 2019

Chief Complain: pain on his right thigh

History
Patient taken to Ulin hospital because pain on his left thigh 5 hours before admission. He got a
accident when he was riding a motorcycle. He hit by another motorcycle, after that the patient fall
down. He felt, his thigh was really pain. Pain increased when he change position. VAS 9.
He still can move his thumb. Dizziness(-), nausea(-) and vomiting(-). The patient already got a
traditional massage, but there is no change, he still feel pain on his right thigh
 Primary survey

• Airway : Clear. talk(+), snoring(-), Gurgling(-)

• Breathing : Symmetric, RR : 20x/minute, lesion(-), SpO2 :98% without
O2
• Circulation : HR : 78x/ minute(warm extremity), BP : 130/90 mmHg,
active bleeding(-)
• Disabilty : E4V5M6, pupil equal 3mm/3mm, light reflex(+/+),
lateralization (-/-)
 Secondary survey

•A :-
•M :-
•P :-
•L : 10.00 WITA 22/3/2019
•E : Binuang
Vital Sign
• GCS : E4V5M6
• BP : 130/90 mmHg
• HR : 78 bpm
• RR : 20 tpm
•T : 36,8o C
• CRT : <2 second
• SpO2 : 98% without O2
Physical Examination
Head/Neck • pale conjungtiva (-/-), sclera icteric (-/-)

• I : symmetric respiratory movement

• P : symmetric VF
Chest • P : sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

• I : distention (-), mass (-), lesion(-)

• A : bowel sound(+) normal 6-7x/minute
Abdomen • P : tympani(+)
• P : tenderness (-) rebound tenderness (-), muscular rigidity (-)

Extremities • warm (+), edema (-), pale (-)

 Status Localized

At regio pelvis sinistra:

Look : vulnus(-), deformity(+), swelling(+), interna rotasion(+)
Feel : Warm (-), tenderness(+), sensory distal(+), CRT <2 second,
pain(+)
Move : ROM limited due to pain
Clinical Pictures
Hip joint and Femur Xray at Ulin Hospital
23/3/2019
 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 13.6 12,00-16,00 g/dl
Leukosit 12.6 4,0-10,5 ribu/ul
Eritrosit 4.5 3,90-5,50 juta/ul
Hematokrit 39.5 37,00-47,00 vol%
Trombosit 270 150-450 ribu/ul
RDW-CV 13 11,5-14,7 %
MCV 87.8 80,0-97,0 fl
MCH 30.2 27,0-32,0 pg
MCHC 34.4 32,0- 38,0 %
Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
PT 10 9,9-13,5 detik
INR 0.93
APTT 25.2 22,2-37,0 detik
GDS 145 <200
SGOT 47 0-46 U/l
SGPT 35 0-45 U/l
Ureum 30 10-50 mg/dl
Creatinin 0.91 0,7-1,4 mg/dl
Natrium 138 135-146 mmol/l
Kalium 4.2 3,4-5,4 mmol/l
Chlorida 107 95-100 mmol/l
Diagnosis
Posterior Dislocation of Right Hip Joint
Management
Treatment on ER
• IVFD NaCl 0,9% 20 tpm
• Inj ketorolac 3x30 mg
• Inj ranitidine 2x1 amp