CASE REPORT SESSION

PATIENT IDENTITY
Name : .Mrs. T
Age : 14 years Old
Sex : Female
Religion : Moslem
Address : Air Tawar
Occupation : Student
Date of Admittance : 25 th September 2018
 PRIMARY SURVEY
Airway : Snoring (-) , Gargling (-) , Obstruction (-)
Impression : Clear
Breathing : RR= 22x /minutes ; spontaneous
thoracoabdominal type, symetrical ; point of
tenderness (-)
Circulation : BP : 120/80 mmHg , Pulse : 80x/minutes,
regular, SpO2: 100 % , syanotic (-), warm acral,
CRT < 2’
 Disability :
PCS :E4M6V5=15 (CMC) ; pupilary reflex : +/+, isokor D:
3mm/3mm
 Exposure : Impression : Clear
HISTORY TAKING
 CHIEF COMPLAINT

Pain at the left leg after traffict accident about 25 minutes ago
before come to the emergecy department of SITI RAHMAH
HOSPITAL
 HISTORY of ILNESS
• Pain at the left leg after traffict accident about 25 minutes ago
before come to the Emergecy Department of SITI RAHMAH
HOSPITAL. Leg pain suffered when pressed. And bleeding (+)
 MECHANISM of TRAUMA

• Patient was a passanger of a motorcycle. Her sister drove it too

faster, suddenly she lost control and crushing the garbage car
in front of them.They were fall on to the ground and roll on the
road. Then, She did not remember what happen after that. The
patient wears a helmet with the glass open so that there is
swelling on her forehead, headache (+) .
• History of fainting (+) : The patient fainted about 5 minutes,
the patient became concious when the people around her
bring her to The Emergency Department. Nausea (-), vomitting
(-)
• Bleeding from mouth (-) , ears (-), nose (-)
 HISTORY of PREVIOUS ILNESS
• Traumatic (-)
• Hyperension (-)
• DM (-)
• Operation (-)
 ALLERGIC’S HISTORY
• No allergics history
 FAMILY HISTORY
• No family history of Ilness
 SECONDARY SURVEY
• General status : Moderate ilness/ well nourished /compos
mentis
• Vital sign :
BP : 120/80 mmHg
P : 80X/minutes
RR : 22 x/minutes
T : 36,7oC
• Head

– Eye : anemic conjungiva (-/-), icteric sklera (-/-), isocor papilary ,

hematom palpebra superior inferior oculi dextra
– Nose : bleeding (-), deviation septum (-), epistaxsis (-), rinorrhea
(-)
– Ears : bleeding (-/-), otorrhea (-/-)

• Neck : enlarge of limph (-), trachea deviation (-)

• Mouth : cyanotic (-), vulnus excoriatum (+) labia superior

• Thorax :
• Pulmo
–I : Normo chest , symetrical chest movement
–P : Symetrical Tactil fremitus
–P : Sonor on the field of lung
–A : vesicular (+) , wheezing (-/-) rhonci (-/-)
• Cor:
–I : ictus cordis is not visible
–P : ictus cordis is not lifted
–P : dim , normal
–A : regullar (+), mur-mur (-)
• Abdomen:

I : bulge (-), venectation (-)

A : Normal (+) intestinal noise
P : soepel (+), tenderness (-), mass and protrusion (-)
P : tympani
 LOCAL STATUS
• HEAD :
1. Look :
Skin : vulnus contussum et regio frontalis
Shape : round swelling , deformity (-)
Size : 6x5x3 cm , hiperemis(+)
Feel : point of tenderness (+) , crepitation (-)
2.Look :
Skin : vulnus contussum et palpebra superior inferior oculi
dextra, hiperemis(+)
Shape : swelling round , deformity (-) ,
Size : around the eye
Feel : point of tenderness (+) , crepitation (-)
• RIGHT ARM :
Look :
Skin : vulnus excoriatum et digiti III,IV manus dextra
Shape : swelling round , deformity (+)
Size : difficult to determine, hiperemis(+)
Feel : point of tenderness (+) , crepitation (+)
NVD = sensibility is good, Radialis Artery palpable, CRT < 2”
Move : limitery of active and passive movement
• LEFT LEG :
Look :
Skin : vulnus laceratum et cruris anterior sinistra, bleeding
(+), Bone expose (-)
Shape : swelling round , deformity (+)
Size : 5x4x1 cm, hiperemis(+)
Feel : Point of tenderness (+) , crepitation (+)
NVD = sensibility is good,Dorsalis Pedis Artery and tibialis
posterior artery palpable, CRT < 2”
• LEFT LEG :
Move : active and passive motion of hip joint and knee joint cant
be evaluated due to pain
 Assesment 1
CKR GCS 15
VC et frontalis
VE digiti III,IV manus dextra
VL 1/3 proximal cruris anterior sinistra
 LABORATORY FINDNGS :

– Hemoglobin : 9,5 g/dl

– Hematokrit : 30,0%
– Leukosit : 24.600
– Trombosit : 208.000
– GDR : 114 mg/dl
IMAGING
• MANUS DEXTRA
Closed fracture digiti III phalanx
proximal manus dextra
completed
• CRURIS ANTERIOR SINISTRA
Closed fracture 1/3 proximal os
tibia sinistra completed
 Assesment 2
• Mild Head Injury GCS 15
• Vulnus Contusum et frontalis
• Closed fracture digiti III phalanx proximal manus dextra
completed
• Closed fracture 1/3 proximal os tibia sinistra completed
 PLANNING
• ORIF digiti III phalanx proximal manus dextra
• ORIF 1/3 proximal os tibia sinistra
 MANAGEMENT
• RL drip ketorolac 1 amp 12 jam/kolf
• Inj. Ceftriaxone 2 x 1
• Inj. Ranitidin 2 x 1
THANK YOU