*MORNING CASE

SITI AISYAH KARIMUNA

K1A1 14 042
 Name : Mr. W
Age : 46 years old
Address : Wolasi Village
Occupation : Enterpreneur
Admission : November, 27th 2019 (18.12 pm)
Doctor in Charge : dr. Tri Tuty Hendarwati, Sp.OT

*
IDENTITY
 (at 18.12 pm)

A Clear, cervical spine control

B Respiratory rate 20x/m, spontaneous,

symmetris, regular, vesicular type

C Blood Pressure 160/100 mmHg

Pulse 92x/m, reguler, strong

D Glasgow Coma Scale (E4M6V5), pupil isochoric,

Light reflex +/+

E Temperature 38.3OC/axillary
 SECONDARY SURVEY
Main complain: Pain in right of lower extremities (at 18.18 pm)
History taking:
Suffered since 7 hours before enter from the hospital due to
traffic accident.

Mechanism of trauma: The patient was ride a minivan as a passenger . There is a

big truck which brake failure. The truck move backwards and crash the car.
He jump out from the car and the truck grind the right foot of the patient
History of Trauma:
 There was no history of unconsciousness.
 There were history of nausea (-) and vomiting (-)
 There was no history of alcohol and drugs consumption.
 There was a history of previous medication : IVFD, analgetic, antibiotic

HISTORY TAKING
 SECONDARY SURVEY
(at 18.18 pm)
General State
Moderate Illness, obecity nourish, composmentis.

Vital Sign
BP : 160/100 mmHg
HR : 92x/minutes, regular, strong
RR : 22x/minutes, spontaneous, symmetric,
reguler
T : 38.3OC/axillar
VAS :7/10
 Head : Normally
Face : Normally
Eyes : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
Chest : Normally
Abdomen : Normally
Upper limb : Localized State
Lower limb : Localized state
Genitalia : Normally

PRESENT STATE
SECONDARY SURVEY
 • Upper Limb
*
Inspection : Deformity (+), hematoma (+), swelling (+), wound (+)
crush injury
S
Palpation : Tenderness (+) T
A
T
*ROM : Active and passive movement glenohumeral joint limited due to E
pain
*NVD : Sensibility was good, radialis artery pulsation (+), Capillary refill
time ≤ 2 sec.
 • Lower limb
Inspection : Deformity (+), hematoma (+), swelling (+), wound (+)
fracture comminuted arch
Palpation : Tenderness (+)

 ROM : Active and passive movement ankle joint limited

due to pain
 NVD : Sensibility was good, dorsalis pedis artery pulsation
(+), Capillary refill time ≤ 2 sec.
*Clinical Documentation
 PLAN OF DIAGNOSTIC

• Routine blood test (leukosit, HB,

trombosit)
• Blood chemistry (GDS)
• X-ray cruris sinistra AP/Lat
 LABORATORY FINDING

Value Rujukan

WBC 12.3 3
4.0 – 10.00 10 /uL

HB 13,0 12.0 – 16.0 g/dl

PLT 249 150 – 450 103/uL

GDS 260 70-180 mg/dl

CT 7’00’’ <7’00’’

BT 2’45’’ <3’00’’
RADIOLOGY FINDING

Xray Cruris Sinistra AP/Lat

 *DIAGNOSE
Right Crush Injury Digity

DIFFERENTIAL DIAGNOSE

Compartment Syndrom
Neurovascular Injury
Muscle Contusio
Subluxation Ankle
 *MANAGEMENT
Non-Pharmacological Pharmacological

* Rest • IVFD
* Immobilization • Analgetic injection
* Education (hygiene and • Antibiotic injection
nutrition) • Anti bleeding drips

Consult : Orthopedic Surgeon