POST TEST

CLOSED FRACTURE RIGHT TIBIA

FUBULA
Mentor
Dr. dr. Adrian Khu, Sp.OT, FICS

Presentator
Dzul Akbar Insani - 133307010082
PATIENT STATUS

Room Number : 1009

Day / Date of Entry Room : 13 January 2019
Physician in charge : Dr. dr. Adrian Khu, Sp.OT, FICS

PATIENT IDENTITY:
Name : Tn. Y
Number Of MR : 085730
Age : 33 years old
Gender : female
Religion : Buddha
ANAMNESA

Main complaint : Pain in the right leg calf

Study : Continuous pain of the patient after

falling at 18:00, then the right leg is
difficult in the movement.
Previous Disease History : -
VITAL SIGN
 General Conditions : Good
 Sensorium / GCS : Compos Mentis / 15
 Pulse : 92 x / i
 Respiration : 20 x / i
 Temperature : 37º C

Primary Survey
 A : Airway clear, no airway obstruction
 B : RR : 20 x / I
 C : HR: 92 x / i, regular
 D : GCS : 15 (E4V5M6)
 E : T: 37 ºC
GENERAL STATUS
 Head : Normocephali
 Eyes : Pupil: Isokor (+ / +)
 Sclera : Ikterik (- / -)
 Conjunctiva : Anemis (- / -)
 Light reflex : (+ / +)
 Ear : Normal shape, secretions (-)
 Nose : Normal shape, hyperemic konka (-), septal deviation (-)
 Mouth : Normal shape, cyanosis (-)
 Neck : Lymph nodes enlargement (-)

Thorax (Lungs)
 Inspection : fusiform symmetrical chest shape
 Palpation : right = left stem fremitus
 Percussion : sonor
 Auscultation : Vesikuler
Heart
 Inspection : ictus cordis is not visible
 Palpation : ictus cordis palpable
 Percussion : dim, right and left heart limits cannot be assessed
 Auscultation : S1S2 normal, Gallop (-), Murmur (-)

Abdomen
 Inspection : symmetrical
 Palpation : soepel, tenderness (-), hepatomegaly (-),
splenomegaly (-)
 Percussion : timpani
 Auscultation : peristalsis (+) normal impression

Extremity
 Superior : warm + / +, pain -/-, edema - / -
 Inferior : warm + / +, pain - / -, edema - / -
Orthopedic examination

Look
Swelling in the tibia fibula region
Feel
Pain (+)
Move
Rigidity (+), contracture (-)

Temporary Diagnosis:
closed fracture right tibia fibula
Recommendation:
- Laboratory examination (complete blood, clotting time, bleeding
time)
Laboratory examination

HEMATOLOGI

No. Pemeriksaan Hasil Satuan Normal

1 Hemoglobin 12.7 g/dl 13.5 – 15.5

2 Leukosit 7.16 103/uL 5 – 11

Laju Endap
3 1.4 mm/jam 0 – 20
Darah

4 Trombosit 313 103/uL 150 – 450

5 Hematocrit 38.4 % 30.5 – 45.0

6 Eritrosit 6.07 10^6/mm3 4.50 – 6.50

7 MCV 63.3 fL 75.0 – 95.0

8 MCH 21 Pg 27.0 – 31.0

9 MCHC 33.1 g/dl 32.0 – 34.0

 LIVER FUNCTION
No. Pemeriksaan Hasil Satuan Normal Metode
1 SGOT 13 U/L 0 - 37 -
2 SGPT 26 U/L 12 - 65 .

RENAL FUNCTION

No Pemeriksaan Hasil Satuan Normal Metode

1 Ureum darah 26 mg/dl 15 - 38 -

2 Kreatinin 0.85 mg/dL 0.55 - 1.30 -
RADIOLOGI - Pre Surgery
Work Diagnosis
Closed fracture right tibia fibula
Planning
 RL IVFD fluids 20 gtt / i macro
 ORIF
 The patient is asked to fast before surgery
 Ceftriaxone 1gr/ 12 hours
 Ketorolac Inj 1 amp / 8 hours IV
 Ranitidine 1 amp / 12 hours IV

Action:
1. Supine position under general anesthesia
2. Disinfectants and drapping procedures
3. Incision and identification of fractures
4. Wash the wound and cover the wound
5. Reduction and installation of ORIF
RADIOLOGI - Post Surgery
Post operative Assessment :

General condition : satisfying

Awareness level : awake
Breath : free
Respiratory : spontaneous

Education:
1. Do not maneuver which can inhibit wound
healing and
2. Schedule a re-consultation to monitor the
results of the action.
THANK YOU