“MINI-Cex “

Oleh : Ni Nyoman Sulindri Intan Sari

018.06.0065
Pembimbing :dr.I Gusti Bagus Arie M. B., M.Biomed , Sp,OT
 IDENTITAS PASIEN
Nama : Tn.INT
Tanggal Lahir : 01-07-1957
Usia : 66 Tahun
Jenis Kelamin : Laki-laki
Suku/Bangsa : Bali/Indonesia
Pendidikan : SMP
Pekerjaan : Tukang
Alamat : Nusa Penida
Agama : Hindu
Status Perkawinan : Menikah
No. RM : 318476
Waktu Pemeriksaan d : 21 Febuari 2024
ruang Kusamba :
 01
Anamnesis
Keluhan utama : Berjalan Pincang

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 Riwayat Penyakit Sekaang
MOI : Pasien sedang memperbaiki tembok di rumahnya pada
tanggal 29 desember 2023, kemudian tiba-tiba pasien
terjatuh dengan ketinggian sekitar 1 meter dan tertimpa
pecahan beton dinding tembok. Pasien mengatakan posisi
jatuh terduduk menghadap ke kiri dan paha kiri menumpu
badan.

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 Setelah pasien mengalami hal tersebut pasien
mengeluhkan nyeri dan bengkak pada daerah
pinggang kiri menjalar hingga tumit kaki.
Pasien mengaku awalnya masih dapat bisa
berjalan, setelah 4 hari kemudian pasien tidak
biasa berjalan dan memutuskan untuk
melakukan pengobatan ke dukun. Pasien
mengaku keluhanya membaik

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● Setelah 25 hari post kejadian jatuh pasien mengalami kesulitan dalam
berjalan hingga mengganggu aktifitas pasien sehari hari. Pasien merasa
keluhan nyerinya membaik ketika berjalan menggunakan tongkat,
menekukan pahanya kearah samping dan keluhan memberat ketika
berjalan, atau perubahan posisi , keluhan nyeri ini tidak disertai demam,
ada sensai kesemutan +, pasien mengaku BAK + BAB + Lancar ,
pasien menyangkal mengalami penurunan BB badan drastis dalam 3
bulan, nafsu makan pasien tidak ada keluhan
● Riwayat Penyakit dahulu :
Riwayat trauma :disangkal
Riwayat Hipertensi : disangkal
Riwayat Diabetes Melitus: disangkal
Riwayat Stroke : disangkal
Riwayat Keganasan : disangkal
● Riwayat penyakit keluarga: -
● Riwayat Sosial Ekonomi : perokok +minum alkhol +
● Riwayat Alergi :-
● Riwayat Pengobatan : Non medis ( Diurut )
●
 PRIMARY
SURVEY
Primary Survey :

Airway & C-Spine control : Tidak ada obstruksi

● Breathing : 18 x/menit
● Circulation & Bleding control: TD: 127/85 mmHg
Nadi : 86 x/menit , regular, kuat angkat
● Disability : GCS 15 Komposmentis E4V5M6. Pupil bulat
isokor,Refleks cahaya langsung &tidak langsung +/+
● Exposure Enviroment : tidak ada jejas lain selain di paha kiri , T37 derajat
aksila
 SECONDARY SURVEY
● Kepala : Normocepali, deformitas –
● Wajah : simetris kiri dan kanaN
● Mata : Konjuntiva anemis - , edema – sikatrik
● THT : deformitaspada hidung mulut telinga
-
● Leher : pembesaran KGB -, deviasi trakea –
● Thorax : Cor : S1 S2 tunggal regular , murmur -,
● Pulmo : vesikuler, ronki –
● Abdomen : Distensi - , bissing usus +
● Akral : hangat + pitting edemea –
 STATUS
LOKALIS
Regio pelvis
● Look : Deformitas (+), eksorotasi dari hip
joint +,Swelling + edema -, hematoma
Shortening +
● Feel : nyeri tekan +, penonjolan + ,
krepitasi sulit diniali , pulasasi aerteri
dosalis pedis +
 STATUS
LOKALIS

● Look: Deformitasi +: eksternal

rotasi ,Shorthening+
, swelling +, edema -, hematom –
Feel: Nyeri tekan + , teraba hangat +
Move
ROM Aktif:
ektensi (+), fleksi (-), endorotasi ( - )eksorotasi (+)
ROM Pasif
Ektensi(+)minimal , fleksi (+) minimal , endorotasi (-)
, eksorotasi (+)
NVD : CRT < 2 detik , palpasi arteri dorsalis pedsis +
sensitivitas baik
 Diagnosa Banding

Dislokasi hip Fraktur femur

 Usulan Pemeriksaan Penunjang
a. Rontgen Pelvis AP, Rontgen Femur AP/Laetral Sinistra
b. Darah rutin
 DIAGNOSIS
● Dislokasi Hip Anterior sinistra
● Fraktur Acetabulumn sinsitra
 TATALAKSANA
Medikamentosa
Konservatif :
Non Medikamenta
Suportif: IVD RL
● Tirah baring
● Imobilisasi tidur Simtomatis : Ketorolak 3 x 30mg
IV ,Antibiotik profilaksis
Causatif :4 R
1. Recognize
2. Reduction: reduksi terbuka
3. Retention : continuous Traction>> Skin traction >>
Bipolar Hemiaatroplasty
4. Rehabilitation
 Prognosis
● Quo ad vitam : dubia ad dubia
● Quo ad Sanationam : dubia ad dubia
● Quo ad functionam : dubia ad dubia
● Quo ad cosmeticam: dubia ad dubia
 Komplikasi
● Akut : trauma vessels (perdarahan), trauma visceral , sindrom
kompartemen
● Kronik : Delayed Union, Non Union ,Malunuion
 Kie
1.edukasi mengenai kondisi pasien terhadap penderita dan keluarga penderita
2. edukasi mengenai tatalaksana awal jika mengalami trauma
3. edukasi untuk segera ke pelayanan medis dan tidak melakukan pengobatan tradisonal
seperti diurut atau kepada orang yang bukan memiliki kompetensi
4. menjelasakan penyembuhan tulang
5. edukasi untuk tetap melakukan perawatan setelah dilakukan operasi
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