Mrs.

Hasni/ 55 Years Old/01130234/ BPJS

Attending: dr. Adri Yandra Hidayat, SpOT

August 6th 2023

Filza
Kono – Reza
Rian – Fikra
Irsyad
 Mrs. Hasni/ 55 Years Old/01130234/ BPJS
Attending: dr. Adri Yandra Hidayat, SpOT
Trauma, Alert response
Primary Survey
Objective Assessment Action
Airway maintenance Snoring (-), gurgling (-), stridor (-), saturation 99 % Patent airway (+) Monitoring airway
with restriction of
cervical spine motion

Breathing and RR 20 x/minute, symmetrical chest wall movement, Breathing and ventilation clear (+) Monitoring breath
ventilation jugular venous distention (-), trachea in the middle, rhythm and O2
normal breath sound R = L, resonance percussion, saturation
saturation 99 %

Circulation and warm (+), cyanotic (-), pulse 92 bpm (adequate), Hemodynamic Stable IVFD RL 1500 cc/24 hours
hemorrhagic control regular adequate, CRT < 2’s, BP 150/92 mmHg

Disability (neurology GCS 15 E4M6V5, round pupils, equal 2/2 mm, Decrease of consciousness (-) Observation level of
evaluation) pupillary light direct & indirect reflex +/+, consciousness,
lateralization cannot be assessed

Exposure T: 36,7 C No hypothermia Covered with blanked

 Mrs. Hasni/ 55 Years Old/01130234/ BPJS
Attending: dr. Adri Yandra Hidayat, SpOT
Secondary Survey:
• The patient complained of pain in the right leg since 2 hours before admission.
• Mechanism of trauma, the patient was walking to the mosque in the morning
and accidentally slipped on the road and fell to the right side. There was no
open wound. There were no injuries to other parts of the body.
• After the incident, the patient remained conscious, with no vomiting, seizures
or severe headache.
• The patient was taken directly to AA Hospital for further treatment.
 Mrs. Hasni/ 55 Years Old/01130234/ BPJS
Attending: dr. Adri Yandra Hidayat,

History of past illness

• A : History of an allergic (-)
• M: Last medication (-)
• P : History of past illnesses (-)
• L : Last meal 10 hours before admission
• E : Work accident
 Physical Examination

• Awareness : GCS 15 E4M6V5

• Vital Sign
• BP : 152/90 mmHg
• HR : 92 bpm
• RR : 20 x/m
• Temp : 36.7 oC
• SpO2 : 99 % room air
 Physical Examination
• Head: wound (-), hematoma (-) • Heart: Normal heart sound regular, no gallop,
• Eyes: Anemic conjunctiva(-/-), hematoma (-/-), no murmur
icteric sclera (-/-), round pupils, equal pupil : • Abdomen:
2/2mm, pupillary light reflex direct and indirect - I : distended (-), bruise (-), open wound (-)
(+/+)
- A: normal bowel sound
• Neck: wound (-), hematoma (-)
- P: Firm, Muscle rigidity (-), tenderness
• Chest:
(-), defense muscular (-)
- I : Symmetrical chest wall movement, - P: tympani
lesions (-), deformity (-), active bleeding(-)
• Extremity: localize status
- P : fremitus equal left and right,
crepitation(-)
- P : Resonance (+/+)
- A : Vesicular sound (+/+),
rales (-/-), wheezing (-/-)
 Localize Status of Right Lower Leg
- Look: swelling (+), deformity (-), laceration (-), excoriation (+)

- Feel: tenderness (+), vulnus excoriation at ankle joint right lower

leg, size 3x3 cm. Dorsalis pedis artery pulsation (++), posterior
tibial artery pulsation (++), warm acral, CRT <2 sec, normal
sensory
SpO2 digiti 1-5 100%

- Move:
Active and passive knee joint movement limited due to pain
Active and passive movement of ankle joint is normal
Localize Status of Lower Leg
 Working Diagnosis
• Suspected Right Lower Ankle Fracture
Performed
Therapy in ER AA Hospital :
- RL 1500 cc/24 hours ivfd
- Ketorolac 30 mg iv
- Ranitidine 50 mg iv
Planning:
• Chest X-ray, right lower ankle x-ray
• Laboratory test
• Consult to orthopedic surgeon
 Right Foot (August, 6th 2023)

Discontinuity of Right Foot

• Site : Distal
• Extend : Complete
• Configuration : Oblique
• Displacement : Inferoposterior
Laboratory Result at Arifin Achmad Hospital
(August 6th 2023)
 Diagnosis Performed

Closed Fracture Maleolus Medial et dr. Adri, Sp.OT

Lateral Right Ankle Supination - Inpatient
- Posterior Splint
Adduction Stage 1 - Ketorolac 3x30 IV
- Plan to elective ORIF
ICD X:
S82. 6 for Fracture of lateral malleolus
is a medical classification as listed by
WHO under the range
Posterior Splint Posterior Splint
THANK YOU