WEEKLY REPORT

DM Jordi dan DM Sarliance

Bagian/ SMF Ilmu Bedah

RSUD Prof. Dr. W.Z. Johannes
Kupang
IDENTITY

• Name : An. MJ
• Gender : Male
• Age : 7 y.o
• Occupation : Student (Emelentary School)
• Address : Alak
• MRS : 30/12/2020
• MR Number : 540383
 ANAMNESIS

• Main complaint: pain in the lower right leg

• History of Present Disease : Patient, male, 7 y.o came to the hospital with pain
sensation at lower right foot which caused by falling from his bycicle
approximately 1,5 hours before go to the hospital. Complains is also
accompanied with pain, and looks brushy but doesn’t appear any active blood.
Because of the broken bone and continous pain, patient was brought to the
hospital. Decrease of conciousness (-), nausea (-), vomiting (-), headache (-),
Defecation and Urinate function normal.
• History of Past Disease -
• History of Medication: -
• History of Genetical Disease :-
• History of Immunization
Patient already has all of the basic immunization on schedule
• History of Breast Milk
Patient get breast milk until 6 months
• History of Pregnancy
When pregnant, patient’s mother never experienced any disease
• History of Labor
Patient’s labor in enough months, per vaginam, born at puskesmas Alak, Kota Kupang,
assisted by midwife
MECHANISM OF INJURY

Patient, male, 7 y.o was rode a bicycle with high

speed at a flat road, and hitted by another bicycle
which rode by his friend from the left side. Patient
fell in high speed to the right side and hit the road
with bended foot position
PHYSICAL EXAMINATION

Primary survey
A: Clear, snoring (-) gurgling (-)
B: Spontaneous, chest expansion symmetrical
C: BP 110/60 mmHg, HR 77x/min, regular, CRT < 2”
D: Alert
E: Broken bone at lower right foot
PHYSICAL EXAMINATION

• General state: Moderate illness

• GCS : E4 V5 M6 (Compos Mentis)
• TTV
• BP : 110/60 mmHg
• HR : 77 x/ menit
• RR : 20 x/ menit
• T : 36,9 oC
• SpO2 : 100 %

• Weight : 30 kg, Height: 122 cm

ORTHOPEDIC’S PHYSICAL EXAMINATION

• Look : split attached at lower right foot, looks

edema (swelling) at right pedis
• Feel : pain (+) at cruris region
• Move : hard to move (flexion and extention)
• NVD : pulsation (+), regular , lifting strength
• Head : Normocephal
• Eyes : Conjungtive : Anemis (-/-), icteric sclera (-/-), pupil
( 2mm/2 mm) RCL (+/+)
• Nose : Blood cloth (-/-), Rhinorea(-/-)
• Mouth : Lip mucous dry (-), cyanotic (-)
• Ear : Othorea (-/-), tragus pain sensation (-)
• Neck : KGB swelling (-), thyroid swelling (-)
• Thorax

Form : Normal, enlargement of vein (-), scar (-)

• Pulmo
• Inspection : Symmetrical when static and dynamic,
enlargement of intercostal (-), scar (-)
• Palpation : Vocal Fremitus D=S normal
• Percussion : Sonor (+/+)
• Auscultation : Vesicular (+/+), Wheezing (-/-), Ronchi (-/-)

• Cardiac
• Inspeksi : Ictus cordis appear in ics IV regio midclavicula
• Palpasi : Ictus cordis appear di ics IV regio mid clavicula
• Auskultasi : S1-S2 reguler, tunggal, murmur (-), gallop (-)
• Abdomen
• Inspection : looks flat, scar/ mass (-)
• Auscultation : Bowel noise (+) normal
• Palpation : Supel, hepar and lien normal state
• Percussion : Timpani all abdominal region
• Extremity
• Warn extremities, CRT < 2 dtk, nyeri tekan pada region cruris dextra,
edema pedis dextra
LOCAL STATE
 CLINICAL ASSESMENT

• Closed fracture 1/3 mid os. right tibia , 1/3 proximal os. right fibula
 LABORATORY
IDTITAS

30/12/2020 Unit Reference

Hemoglobin 11.4 g/dL 10,8-15,6

Leukosit 11,41 x 10^3 /uL 4,50-13,50x 10^3 /uL

Trombosit 328 x 10^3 181-521

Na 139mmol/L 132-147

K 3,02 mmol/L (L) 3,5 – 4, 5

Cl 101 mmol/L 96-111

Ca Ion 1.26 mmol/L 1,12-1,32

Glukosa 123 mg/dL 70-150

PT/APTT 12.30 / 23.30 (L) detik

Radiographic examination (Cruris
Region)

A : Malalignment (+)
B : bone discontinuity appearance,
fracture complete oblique 1/3 mid os.
tibia dextra, 1/3 proximal fibula
dextra
C : no cartilage damage
S : soft tissue swelling (-)
 WORKING DIAGNOSIS

• Closed fracture complete oblique 1/3 mid os. right tibia, 1/3 proximal os. right
fibula

• Mild Hypocalemia
PENATALAKSANAAN

• IVFD RL 1700 cc dalam 24 jam (24 tpm)

• Inj. Ketorolac 15 mg (IV)
• Aspar K 3x300mg (PO)
• Splint attachment
• Planning: Debridement dan ORIF
TERIMAKASIH