Department of Surgery

February 27, 2015

Name : Tn. S
Age
: 42 y.o
Sex
: Male
Address : Lamongan
Date examination: Feb 27, 2015

Chief complaint :

Pain of his body

MOI :
Patient complained pain of his body especially in right leg, right
shoulder and face. Post disabit when he accompanied her girl friend
in her house. There was 3 person did it suddenly. They let him alone
when he couldnt do anything. He could remember the accident.
Vomit -, headache -. Unconsiousness -.

Airway and spine control : clear (+),

snorring (-), gargling (-), potensial
obstruction (-)
Breathing : spontan, simetric (+), RR
24x/minutes, ves/ves, rh-/-, wh-/Circulation : PR 90x/minutes, acral warm dry
red, CRT < 2, Sp02 distal 99%, blood
presure 95/67 mmHg
Disability : GCS 456, LP +/+, isocor pupil
3mm/3mm, lateralisasiExposure : temp 35

History past illness History of social, economic :Status Generalis

Head and neck : anemic (-), icteric (-), cyanosis (-),
dyspneu (-) vulnus stasum
Thorax : simetric (+), retraction (-)
Pulmo : ves/ves, rh-/-, wh-/Cor : S1S2 single, murmur (-), gallop (-), lession Abdomen : flat, soepel, tympani (+), liver and spleen
were not palpable, bowel sound (+), lession-, injury
Extremities : acral warm, dry, red, lession- multiple
vulnus appertum

Et regio antebracii dextra :

- Look : multiple vulnus appertum, bone
exposure +, deformitas +, degloving +
- Feel : pain +, pultation of distal arteri +
99%, laceration degloving 20cm
- Move : ROM wrist until digiti +
Regio frontalis :
- Look : Vulnus stasum et regio frontal dextra
10 cm
- Move : Minimal movement ec pain

Clue and cue

Male, 42 years old
Pain of her body
Et regio antebracii dextra :
- Look : multiple vulnus appertum, bone exposure
+, deformitas +, degloving +
- Feel : pain +, pultation of distal arteri + 99%,
laceration degloving 20cm
- Move : ROM wrist until digiti +
Regio frontalis :
- Look : Vulnus stasum et regio frontal dextra 10
cm
- Move : Minimal movement ec pain

Open fracture antebracii Dextra degloving

Open fracture brain expose frontral sinitra

CBC
Random Blood Glucose
Head CT Scan without contras
Antebracii Photo

Eritrosit : 5,27
Diff : 8.7/1.7/37.9/47.5/4.2
Hct : 42,6
Hb : 15,7
LED : 9/15
Leukosit : 19.400
Trombosit : 382.000
GDA 205
SGOT : 29
SGPT : 51
RDW : 12
MCV : 80.80
MCHC 36.9
MPV : 6

Open fracture ulna 1/3 distal dextra

Ivfd Assering 1500 cc/24 h

Inj ceftriaxon 2 gr iv
Inj tentagram 1 amp
Inj ranitidine 2x50 mg iv
Inj metronidazole 3x30 mg iv
SPALK
c/ dr. AAO, Sp.OT Pro cito op
c/ dr. Orizanov, Sp.An acc op prepare 1
bag WB

Subjective complaint
Vital sign

Explain to the patients family about the

diagnosis, etiology, intervention of therapy,
complication, and prognosis.