CASE REPORT

Tuesday, July 16th 2013

Team of duty: Dr. Fachrul Razi
Dr. Hendra
Dr. Meutia
Dr. Ist Kumala
Dr. Munawar
Dr. Aswad
Dr. Iwan
Dr. Jauhari
Dr. Nasrul
I.

Patient Identity
Name
: Riyandi
Age
: 11 years old
Sex
: Boy
Address
: Ds. Beuah, Kec. Delima, Kab. Sigli
MR
: 96 13 82
Phone
: 085370232482

II.

Chief Complaint:
Pain at the right bottom

III.

Present illness history

The patient was come to RSUZA with a chief complain pain at
the right bottom for 7 days ago. Patient was sitting on chair and
suddenly he got pain at the right bottom because foreign body
like nail. He was operated at district hospital already about 3
days before come.

IV.

Physical examination
Primary Survey
Air Way : clear
Breathing : Spontaneous, 20 breaths/min
Circulation
: Blood Pressure: 120/80 mmHg, Pulse: 88
beats/min
Disability : GCS E4M6V5: 15
Exposure
L/S at the right bottom
Look : hematoma (+), wound (+) 2 cm sutured
Feel : pain (+)

V.

Assessment:
Suspect foreign body at the right bottom.

VI.

Management
IVFD RL 15 drips/min
Cefotaxime injection 500 mg
Ketorolac 1 % injection
Routine laboratory examination
Radiology examination

VII.

Routine Laboratory
Haemoglobin
White Blood Count
Platelets
Hematocrit
CT/BT

VIII.

X-ray result :
Foreign body at the right femur region

IX.
X.

XI.

examination
: 13 gr/dl
: 6.000 mg %
: 251.000/ul
: 36 %
: 6/2

Diagnose
Foreign body at the right femur. (ICD X S21.0)
Planning
Consult to pediatric surgery division:
Elective extraction foreign body
Follow Up

Date
19/07/2
013
POD I

S
Pain (-)

O
General
Condition good
Blood presure
120/70 mmhg
Pulse 86x/minute
RR 20x/minute

A
Foreign
body at the
right femur.
(ICD X
S21.0)

P
IVFD RL 15
gtt/i
Cefotaxime Inj
500 mg/12
hour
Ketorolac 10
mg Inj /8
hour
Diet 750 kcal