Patient Identity

• Name : Nurma
• Age : 44 tahun years old
• Sex : Male
• Address : Kuta Iboh, Aceh Selatan
• MR : 1140750
• Driving License : (+)
• Phone : 085277120012
• Admission time : 00.30 PM
 Time Response
Date/hour Examination Laboratory Radiology Hour of Date/hour DPJP
patient hour Examination Examination Diagnostics patient out
came to ER from ER

Send Result Send Result

24/05/2017 20.00 WIB 20.00 22.00 20.10 21.30 21.30 WIB 13.00 WIB dr. T. Nanta
20.00 WIB WIB WIB WIB WIB Sp.OT
Chief Complaint:
Pain and difficulty moving of the left foot

Present illness history

• The patient was refer from Aceh Selatan distric
hospital to Zainoel Abidin Emergency Room
with a chief complaint Pain and difficulty
moving of the left foot for a day
• The complaint started after the patient was
riding motorcycle with helmet and suddenly the
gir was slip and she felt down to the asphalt
• There were no histories of unconsciousness,
nausea and vomiting.
• Patient was spontaneously opened eyes to,
obeys command, oriented
Physical examination :
Primary survey
• A : Clear
• B : Spontaneous, RR = 20 breaths/minute
Right haemithorax Left haemithorax

Inspection symmetrical, trachea in the middle, JVP was normal

Palpation Crepitation (-) Crepitation (-)
Percution Sonor Sonor
Auscultation Vesiculer Vesiculer

•C : BP : 130/ 80 mmHg, Pulse : 90 beats/minute

•D : GCS E4 M6 V5 =15, isochoric pupil
(3mm/3mm), light reflex (+/+)
E:
L/S at the right clavicle
•L : swelling (+), deformity (+), wound (-)
•F : pain (+), NVD (-)
•M: ROM limited

L/S at the left foot

•L : lacerated wound(-) with size 15 cm was
suture
•F : pain (+), NVD (-)
•M: ROM limited
Secondary survey
• Head : in normal limit
• Thorax :
L/S at the right clavicle
• L : lacerated wound(+) with size 15 cm and 20 cm
was suture
• F : pain (+), NVD (-)
• M: ROM limited

• Abdominal : in normal limit

• Pelvic : in normal limit
• Upper extremity : in normal limit
• Lower extremity :
L/S at the left foot
• L : lacerated wound(+) with size 15 cm
and 20 cm was suture
• F : pain (+), NVD (-)
• M : ROM limited
Klinis dada pasien
 VAS : Moderate

Mild 1-3 Moderate 4-6 Severe 7-10

Non opioid + Opioid + nonopioid + Opioid + nonopioid +
adjuvant adjuvant adjuvant
- COX-2 - Codein - Oxycodone
- Ibuprofen - Propoxyphene - Morphine
- Aspirin - Hydrocodone - Hydromorphone
- Acetaminophen - Tramadol - Fentanyl
Assessment
1. Open fracture of the left foot
2. Close fracture at the right clavicle
Management
• Stop oral intake
• IVFD RL 20 drips/min
• Cefazoline inj 1 gram
• Ketorolac inj 30 mg
• Tetagam inj 250 IU
• Laboratory examination
• Radiology examination
Laboratory result
• Hemoglobin : 8,8 gr/dl
 transfusion
• White Blood Count : 12,300 /ul
• Platelets : 246.000/ul
• Hematocrit : 26 %
• CT/BT : 7’/2’
Radiology result
Thorax AP
• Trachea midline
• There was no fracture at the ribs
• Bronchovascular until lateral
• Costofrenicus and cardiofrenicus angel was
sharply
• Cor in normal limit
• Diprhagma in normal limit
• There was discontinuity of bone at the middle
third at the right clavicle
Left foot AP/Oblique
• Fracture of the 4th metatarsal
Diagnose
1. Open fracture of the 4th of the left
metatarsal (ICD 10 CM S92.01)
2. Close fracture of middle third at the right
clavicle (ICD 10 CM S42.0)
3. Anemia (ICD 10 CM D64.9)
Consult orthopedic division
• Hospitalized
• Arm sling
• Debridement + K- Wire emergency
Operative Report
• Patient in supine position with spinal anesthesia
• Performed debridement with normal saline,
peroxide + povidone iodine
• Performed K-wire at the 4th of the left metatarsal
• Identification tendon flexor digitorum 4th of the
left foot found total ruptured
• Performed repair tendon flexor digitorum 4th of
the left foot with modification kessler
Post Operative Diagnose :
1. Open fracture of the 4th of the left
metatarsal (ICD 10 CM S92.01)
2. Total rupture tendon flexor digitorum 4th
of the left foot
3. Close fracture of middle third at the right
clavicle (ICD 10 CM S42.0)
4. Anemia (ICD 10 CM D64.9)
 Follow Up
Date S O A P
4/9/2017 Pain Vital sign Post Debridement + K - • IVFD RL 20
POD 3 (+) General condition : good Wire + repair total drips/min
decrea BP : 120/80 mmHg rupture tendiny due to • Cefazoline inj 1
se HR : 80 beats/minute gr/ 12 hours
RR : 20 breaths/minute 1. Open fracture of the • Paracetamol drips
Temp : 36,5 C 4th of the left 1 gr/8 hours
metatarsal (ICD 10 CM • Free dietary
L/S at right clavicle : S92.01)
L : Arm sling (+) 2. Total rupture tendon • Mobilization
F : Pain (+), NVD (-) flexor digitorum 4th of
M : ROM limited the left foot
3. Close fracture of
L/S at the left foot middle third at the
L : wound dry right clavicle (ICD 10
F : pain (+), NVD (-) CM S42.0)
M: ROM limited 4. Anemia (ICD 10 CM
D64.9)