REPORT
Name : Mr. J
Age : 50 years old
Sex : Male
Address : Jalan Palapa
Occupation : Driver
Admission : October, 16th 2019 (22.55)
Doctor in Charge : dr. Moh Riza Alizi, M.Kes, Sp.OT
IDENTITY
A Clear, Cervical Spine Control
SURVEY
Anamnesis
Chief complain : Injury on the right cruris region
History Taking
Suffered since 6 pm because of a traffic accident
Mechanism of trauma :
crashing into a car while driving a motorcycle, because of avoiding
public transport car on the right, then the patient was shocked because
there was a car that stopped on the left, the patient hit the car from the
back then fell, the patient's right foot hit the car bumper and then taken
to the hospital Bhayangkara, the patient is then sutured situationally
and must be referred because of swelling. Other trauma mechanism is
unknown
Anamnesis
There was no history of syncope, nausea and vomiting
There was no history of drugs or alcohol consumption
There was no history of nose, mouth and ear bleeding
There was previous treatment situational sutured
SECONDARY SURVEY
GENERAL STATE
Compos mentis, moderate illnes,
good nourish
Head : Within Normal Limit Neck : Within Normal Limit
Face : Within Normal Limit Chest : Within Normal Limit
Eyes : Within Normal Limit Abdomen : Within Normal Limit
Nose : Within Normal Limit Upper limb : Within Normal Limit
Mouth : Within Normal Limit Lower limb : Localized state
Ears : Within Normal Limit
LOCAL STATE
SECONDARY SURVEY
Right Cruris Region
LOCALIZE STATE
I : Deformity (-), swelling (+) Wound (+)
P : Tenderness (+), krepitation (-)
Planning Diagnostic :
Routine Blood
X-Ray right Cruris AP/Lat
Routine Blood
17/9/2019
X-Ray Right Cruris AP/Lat
DIAGNOSIS
IVFD
Antibiotic Consult Orthopedic
Surgeon
Analgetic
PPI
MANAGEMENT