IDENTITYName : Ms. M

Age : 21 years old

Address : Konsel

Admission : November 5th, 2015 at .00

DPJP : dr. Tri Tuti Hendarwati, Sp.OT

HISTORY TAKINGChief Complain : pain at right leg

- Anamnesis : suffered since ±4 hours before admitted to the hospital due to traffic accident.

- Mechanism of trauma : The patient was driving a motorcycle when suddenly hit by a car from the right side.

- No history of unconscious, no history of nausea and vomit.

PRIMARY SURVEY

PatentARR 20x/min regular, spontaneous

thoracoabdominal type, symmetrical BBP 100/70 mmHg

HR = 86 x/min regular, strongC GCS 15 (E4V5M6), pupil isochors,

Ø : 2.5 mm/2.5 mm, light reflex +/+ DT = 36,80 C (axillary) E

Right leg region:I : Deformity (+), swelling (+), hematoma (+), wound (-)

P : Tenderness (+)

ROM : Active and passive movement of the knee and ankle joints are limited due to pain

NVD : Sensibility is good, pulsation of the dorsalis pedis arteries is palpable. Capillary refill time < 2”

SECONDARY SURVEY

DIAGNOSIS clinic Closed fracture at the right lower limb

RADIOLOGICAL FINDINGS

Rigth Cruris X-Ray

AP / Lateral View

DIAGNOSIS RADIOLOGIC Closed comminutive fracture 1/3 middle right tibia

MANAGEMENT IVFD RL Analgesic Antibiotic Consult ortopedi

THANK YOU