Patient identity:

Name : Maimunah
Age : 53 years old
Sex : Female
Address : Kuta Alam, Banda Aceh
MR : 1209887
Phone : 085297654004
Driving license : (+)
Admission Time : 22.05 WIB

Time Response
Date/hour Examination Laboratory Radiology Hour of Date/hour DPJP
patient hour Examination Examination Diagnostics patient
came to out from
ER Send Result Send Result ER

May 13th 22.10 22.15 23.30 22.25 23.45 23.55 May 14th dr.
2019 2019 Armia
22.05 WIB 00.15 Wib Indra,
Sp.OT

Chief complaint
• Pain and difficult to move of the left lower leg
Presenting history
• The patient came to Zainoel Abidin emergency room with chief complain pain and difficult to
move of the left lower leg since 2 hours ago.
• The patient was passenger motorcycle, suddenly she strucked another motocycle from
beside. Her leg hit by the wheel.
• There was no history of decrease of consciousness.
• There was no history of nausea and vomiting.
• Eyes open spontaneously, motoric obey command and verbal oriented.
Physical examination :
Primary survey
• A : Clear
• B : Spontaneous, RR = 18 breaths/minute
•
• C : BP : 130/80 mmhg, Pulse : 86 beats/minute, warm acral, IVFD RL 1500 cc/24 jam
• D: GCS = E4 M6 V5 = 15, isochoric pupil (3mm/3mm), light reflex (+/+)
E : L/S at the left lower leg
• L : Deformity (+), swelling (+), bone expose (-), wound (-)
• F : Pain (+), NVD (-)
• M : ROM limited

Secondary survey :
• Head and neck  normal limit
• Thorax  normal limit
• Abdominal  normal limit
• Upper Extremity  normal limit
• Lower Extremity :
E : L/S at the left lower leg
• L : Deformity (+), swelling (+), bone expose (-), wound (-)
• F : Pain (+), NVD (-)
• M : ROM limited

Assessment:
Close fracture of the left leg

Management:
Immobilization
Drip Tramadol 100 mg
Laboratorium examination
Radiology examination

Laboratory result:
HB : 11,8 g/dL
HT : 34 %
WBC : 10,800 u/l
Platelet : 293.000 u/l
CT : 7’
BT : 2’
Radiology Result
Left cruris AP/Lat :
There were discontinuity of bone at the lower third of the left tibia and fibula

Diagnose
1. Close fracture at the lower third of the left tibia (ICD 10 CM: S42.42)
2. Close fracture at the lower third of the left fibula (ICD 10 CM: S42.41)

Consult to orthopedic division:

Hospitalize
Back slab
Orif Elective

Follow up
Date S O A P

May 15th Pain Vital Sign: Diagnose • IVFD RL 1500cc/

2019 decrease TD : 110/70 mmhg 1. Close fracture at 24 hours
RH 6 HR : 81 x/minute the lower third of • Drip Tramadol
AD 2 RR : 22 x/minute the left tibia (ICD 100 mg/ 8 hours
Temp : 36,6 oC 10 CM: S42.42) • Free Diet
L/S at the left leg: 2. Close fracture at Planning :
L : Backslab (+) the lower third of • Immobilitation
F : pain (+), NVD (-) the left fibula • Orif elective
M : ROM limited (ICD 10 CM:
S42.41)