CHAPTER II

CASE STUDY
2.1. Patient Identity
Name : Mr. Z
Age : 25 years
Gender : Male
Address : Kuta Makmur
Religion : Islam
Medical Record : 09.39.84
Occupation : Gardener
Dates : 02 October 2017
2.2. Anamnesis
a. The Main Complaint
A torn wound on the right foot.
b. Additional Complaint
Wounds have active bleeding, pain, legs are difficult to move.
c. History of the disease

Patients come to the Accident and Emergency department on 30th

september 2017 at 06.00 PM with complaints of torn wounds on the feet after
being hit by lawnmowers on 30th september 2017 at 04.00 PM. According to the
patient's statement a torn wound appears bone and there is active bleeding, pain,
his feet feel cold and the patient feels the patient's leg is difficult to move.
History of fracture (-), history of Allergies (-), smoking (-), history of
Tuberculosis (-), and history of diabetes mellitus (-).
d. History of the past disease
He never has been like this before.
e. History of family disease
There are no family have the same disease as same as his.
f. History of Drug and Therapeutic

No history of drug use and therapy

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2.3. PHISYC EXAMINATION

General condition : Middle
Consiousness : Compos mentis
Vital Sign :
Blood pressure : 110/70 mmHg
Pulse : 86 x/minutes
Respiration : 22 x/minutes
Temperature : 36,4 0 C
Generalis state head to toe :
Head : Normocephal
Eyes : anemic conjungtiva (-/-), icteric of the sclera (-/-), pupil
isokor diameter 3 mm/3mm, light reflex (+/+)
Nose : discharge (-), deviation of septum (-), rinorrhea (-)
Ears : discharge (-), othorrhea (-)
Mouth : dry mucous (-), sianostic (-), coated tongue (-)
Neck : Mass (-) below left region, Lymph node enlargement (-)
Thorax

Cor
Inspection : Ictus cordis (+)
Palpation : Ictus cordis palpated
Percussio : Rightside cardio teritory border :ICS V Sternalis
dextra
Leftside cardio teritory border :ICS VI Midclavicula
sinistra
Upside cardio teritory border :ICS III Parasternalis
sinistra
Auscultatation : BJ I-II Normal reguler, Murmur (-), Gallop (-)

Pulmo
Inspection : Simetry in dynamic and static movement, intercostal
retraction (-), mass (-)
Palpation : Vocal fremitus right = left, trachea deviation (-)
Percussion : Sonor on the lung cavity
Auscultation : Vesikuler breath sound
Wheezing (-), Ronkhi (-)
Abdomen
Inspection : venectasy (-)
Auscultation : peristaltic sound of bowel (+)
Palpation : mass (-), liver or lien enlargement (-)
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Percussion : Tympani on the 4 quadrant abdoment

Ekstremity
Superior : deformity (-), edema (-), cyanotic (-), warm
Inferior :
a/r cruris dextra
Look : There is an open wound on the lower right leg
with an unclear deformity.
Feel : tenderness in the proximal area of the tibia,
there is bleeding, akral cold, the pulse is still
palpable
Move : difficulty moving the foot in the distal
direction and difficult to move the finger

2.4. LABORATORY TEST

1. Hemoglobin : 13,9 gr/dl

2. Hematokrit : 43,1 vol%
3. Erythrocytes : 5.04 million / mm3
4. Leukocytes : 25.41 thousand / mm3
5. CT : 7
6. BT : 145
7. MCV : 85,6 fL
8. MCH : 27,7 pg
9. MCHC : 32,3 g%
10. RDW-CV : 11,9%
11. Trombosit : 225 million / mm3
12. KGDS : 161 mg/dL
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2.5. Radiology

2.6. Work Diagnosis

Open fracture cruris Grade IIIA + Tendon and Arteri tibialis anterior
rupture
2.7. Therapy
1. IVFD RL 20 gtt/i
2. Ceftriaxon 1 g / 12 hours.
3. Ranitidin 1 amp (50 mg)/ 12 hours.
4. Keterolac 1 amp 30mg/ 12 hours
5. Kalnex 1 amp / 8 hours.
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6. Tetanus antitoxin 1500 IU

7. Hecting laceratum
8. Debridement open fracture and repair arteri tibia.

2.8 Follow Up

Date Subject Objective Assesmen Planning Therapy

t
09 Pain in the leg TD: 120/80mmhg open - Blood 1. IVFD RL 20
October Headache (+) HR: 79x/mnt fracture routine gtt/i
2017 Fever (-) RR: 22x/mnt cruris - 2. Ceftriaxon 1 g / 12
Nauseous T: 36,3Cx dextra rontgen hours.
vomit (-/-) Look: laceration a / r 3. Ranitidin 1 amp
Defecation 5x2x3 cm active cruris (50 mg)/ 12 hours
(N) bleeding (+) bone dextra 4. Ketorolac 1 amp
Urinate (N) exposure (+) - (30mg) / 8 hours
Feel: acral cold primary 5. Kalnex 1 amp / 8
CRT <2 sec hecting hours
Move : ROM is a on 6. Tetanus Antitoxin
bit limited lacerati 1500 IU
ons
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01 Pain in the leg TD: 120/80mmhg open 1. IVFD RL 20 gtt/i

October Headache (+) HR: 72x/mnt fracture use of 2. Ceftriaxon 1 g / 12
2017 Fever (-) RR: 22x/mnt cruris casts hours.
Nauseous T: 36C dextra (gips) 3. Ranitidin 1 amp
vomit (-/-) Look: laceration a/r (50 mg)/ 12 hours
Defecation covered bandages cruris 4. Ketorolac 1 amp
(N) Feel: acral cold dextra (30mg) / 8 hours
Urinate (N) CRT <2 sec
Move : ROM is a
bit limited

02 Pain in the leg TD: 130/80mmhg open Debride 1. IVFD RL 20 gtt/i

October Nauseous HR: 82x/mnt fracture ment + 2. Ceftriaxon 1 g / 12
2017 vomit (-/-) RR: 24x/mnt cruris repair hours.
Defecation T : 36,5 dextra arteri 3. Ranitidin 1 amp
(N) Look: laceration and (50 mg)/ 12 hours
Urinate (N) covered bandages tendon 4. Ketorolac 1 amp
Feel: CRT <2 sec a/r (30mg) / 8 hours
Move : ROM is a cruris 5. use of casts (gips)
bit limited dex a/r cruris dextra

03 Pain in the leg TD: 120/80mmhg Open Debride 1. IVFD RL 20 gtt/i

October Nauseous HR: 82x/mnt Fracture ment + 2. Ceftriaxon 1 g / 12
2017 vomit (-/-) RR: 24x/mnt Cruris repair hours.
Defecation T: 36C Dextra arteri 3. Ranitidin 1 amp (50
(N) Look: laceration Grade and mg)/ 12 hours
Urinate (N) covered gips IIIA + tendon 4. Ketorolac 1 amp
Feel: CRT <2 sec Tendon a/r (30mg) / 8 hours
Move : ROM is a and Arteri cruris
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bit limited tibialis dex

anterior
rupture

04 Pain in the TD: 120/80mmhg Open 1. IVFD RL 20 gtt/i

October legs has been HR: 82x/mnt Fracture 2. Ceftriaxon 1 g / 12
2017 reduced RR: 24x/mnt Cruris hours.
Nauseous T: 36C Dextra 3. Ranitidin 1 amp (50
vomit (-/-) Look: laceration Grade IIIA mg)/ 12 hours
Defecation (N) covered bandages + Tendon 4. Ketorolac 1 amp
Urinate (N) and Arteri (30mg) / 8 hours
tibialis
anterior
rupture

05 Pain in the TD: 120/80mmhg Open 1. Cefadroxil 500mg

October legs has been HR: 82x/mnt Fracture go tab 2x1
2017 reduced RR: 24x/mnt Cruris home 2. Ranitidin 150 mg
Nauseous T: 36C Dextra for tab 2x1
vomit (-/-) Look: laceration Grade IIIA treatme 3. Natrium diklofenak
Defecation (N) covered bandages + Tendon nt tab 2x1
Urinate (N) and Arteri (PBJ) 4. Vitamin C tab 2x1
tibialis
anterior
rupture
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2.9 Documentation

Figure 1 : Clinical picture of the patient when first admitted to the hospital

Figure 2 : Primary Hecting

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Figure 3 : . use of casts (gips) a/r cruris dextra

Figure 4 : . use of casts (gips) a/r cruris dextra

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Figure 5 : Debridement + repair arteri and tendon a/r cruris dex