EMERGENCY REPORT RSO Prof Dr R Soeharso Solo Saturday, December 6th, 2014 Consultant : dr. Ismail Mariyanto, Sp.OT(K)

EMERGENCY REPORTRSO Prof Dr R Soeharso Solo Thursday, April 30th, 2015

Consultant : dr. Tito Sumarwoto, Sp.OT(K)dr. Bayuajidr. Zendr. Harrydr. Sidiq

Emergency Room Patient

NoIdentityAssesmentPlan1Jilan 35 y.o27 52 46Burst fracture of 2nd Lumbar Vertebrae Frankel E

Closed fracture of left middle third of clavicle comminutive Allman group IConsult to spine

ORIF2Agus 18 y.o27 52 45Closed fracture of left sub trochanter Fielding IClosed posterior dislocation of left elbowORIF

Emergency Close reduction + slab3Sumartini 33 y.o27 52 48CF of right shaft tibia fibula oblique type. ORIFInward patient

2Out NoIdentityAssesmentAction1.Putri R21 y.o27 52 30Ligamentous injury knee (D)Kocher SlabAnalgetic2Balqis29 y.o27 52 43Contusio musculorum r. elbow (D)Arm slingAnalgetic3Kardi12 y.o27 52 44Contusio musculorum r.antebrachii (S)ArmslingAnalgetic4Lukman11 y.o27 52 40CF Radius ulna distal third (D)Closered + LACAnalgetic3VIPNoIdentityAssesmentPlan----4Refuse for treatment NoIdentityAssesmentAction1.---51st patientIDENTITYName : Agus NovriantoSex: MaleAge : 18 y.oMedical Record: 275245Ward : PKPrimary SurveyMale 18 y.o came to ER with chief complain pain on his left hip after MVA

A: Clear, stable c-spineB: Spontaneous, thoracoabdominally, RR: 20 x/mC: HR: 90 x/m, BP : 120/65 mmHgD: GCS E4V5M6, isochoric pupil (3 mm/3 mm)E: T : 36,5 0C, lesion (+) look at physical examination8History TakingChief Complaint :Pain on the left hipPresent illness :3 hours prior to admission, the patient had a motor vehicle accident. He fell with position his left arm bear the body, and his left hip hit the ground. After that he felt pain on his left hip that aggravated by movement and unable to walk. He also complain pain on his left elbow.There is no pain on other parts of the body. Past illness :There is no history of pain, deformity, or trauma before the accident.

Secondary Survey

Head: no abnormalityNeck: no abnormalityEyes: no abnormalityNose: no abnormalityEars: no abnormalityMouth: no abnormalityChest: no abnormalityAbdominal: no abnormalityExtremities: Lesion (+) look at physical examination10Physical ExaminationLeft hip region :L: skin intact, swelling (+), bruising (+), deformity (+) exorotation, shortening (+)F: NVD (-), Tenderness (+) over proximal femur, Bryant triangle symmetric, (+), LLD : + 1 cmM: ROM hip and knee limited due to pain ROM ankle & toes full

Left elbow:L: skin intact, swelling (+), deformity (+) posterior angulationF: NVD (-), Tenderness (+) around the elbow, Hueter line is brokenM: ROM elbow limited due to pain

1st AssessmentInjury around the left hipDD CF of left sub trochanter femurCF of left intertrochanter femurInjury around left elbowDD posterior dislocation of left elbowFracture dislocation of left elbow

1st Plan

AnalgeticImmobilizationLaboratory examinationX ray

2nd assessmentClosed fracture of left sub trochanter Fielding IAO 31 - A3Closed posterior dislocation of left elbowAO 2.3 B2Tscherne 1ISS : 9VAS : 5-62nd PlanDefinitive treatment : CF left intertrochanter femur ORIFCF left distal radius Emergency Closed Reduction + slab

2nd patientIDENTITYName : JilanSex: Male Age : 35 y.oMedical Record: 275246Ward : PSPrimary SurveyMale 35 y.o, came to emergency room with chief complain pain on his lower back after MVA

A: Clear, stable c-spineB: Spontaneous, thoracoabdominally, RR: 18 x/mC: HR: 98 x/m, BP : 120 / 68 mmHgD: GCS E4V5M6, isochoric pupil (3 mm/3 mm)E: T : 36,7 C, lesion (+) look at physical examination24Secondary surveyChief complaint : Pain on lower backPresent illness :3 hours prior to admission patient was involved in MVA. He fell down with unknown position. After that the patient felt pain on his lower back and unable to walk due to pain. Patient also complain pain on his left shoulder. There was no pain on other part of the body.Past Illness :There was no history of pain, deformity, or trauma before the accident.

Secondary Survey

Head: no abnormalityNeck: no abnormalityEyes: no abnormalityNose: no abnormalityEars: no abnormalityMouth: no abnormalityChest: no abnormalityAbdominal: no abnormalityExtremities: Lesion (+) look at physical examination26Local Physical ExaminationThoracolumbar region :L: skin intact, swelling (+) around thoracolumbar junction, deformity (-)F: NVD (-) tenderness (+) around thoracolumbar junction, step off (-)M: ROM lower extremity full

Left shoulder Region :L : skin intact, swelling (+), bruising (-), skin tenting (-)F : NVD (-), tenderness (+) at middle part of clavicleM : ROM hard to evaluated due to pain, ROM elbow, wrist and finger full27Neurological ExaminationSensoric : normalMotoric :

DSC555C655C755C855T155L255L355L455L555S155Reflex : Bulbocavernous reflex (+)

Sacral sparring : (+)

1st AssessmentInjury around Thoracolumbar regionDD : Compression fracture of thoracolumbar spine Burst fracture of thoracolumbar spine Fracture dislocation of thoracolumbar spineClosed fracture of left middle third claviclePlanImmobilizationAnalgetic X rayLaboratory examination

2nd AssessmentBurst fracture of 2nd Lumbar Vertebrae Frankel EAO : 53.A3Closed fracture of left middle third of clavicle comminutive Allman group IAO : 15. B3VAS : 4-5ISS : 9

PlanDefinitive treatmentBurst fracture consult to Sub SpineClavicle ORIF3rd patientIDENTITYName : SumartiniSex: FemaleAge : 33 y.oMedical Record: 272465Ward : PS Primary SurveyFemale 33 y.o, came to emergency room with chief complain pain on the right lower leg after MVA

A: Clear, stable c-spineB: Spontaneous, thoracoabdominally, RR: 18 x/mC: HR: 98 x/m, BP : 120 / 70mmHgD: GCS E4V5M6, isochoric pupil (3 mm/3 mm)E: T : 36,7 C, lesion (+) at the lower leg39Secondary surveyChief complaint : Pain on right lower legPresent illness :4 hours prior to admission she involved in MVA. She fell from her motorcycle with her right leg hit the ground. After that the patient felt pain at the right lower leg that aggravated by movement and she was unable to walk due to pain. Past Illness :There was no history of pain, deformity, or trauma before the accident.

Secondary Survey

Head: no abnormalityNeck: no abnormalityEyes: no abnormalityNose: no abnormalityEars: no abnormalityMouth: no abnormalityChest: no abnormalityAbdominal: no abnormalityExtremities: Lesion (+) look at physical examination41Local Physical ExaminationRight lower leg region :L : skin intact, swelling (+), bruising(-), deformity (+), valgus angulation. F : NVD (-), Tenderness (+) at the shaft tibia fibulaM : ROM knee and ankle hard to evaluate due to pain

42

1st AssessmentCF of right shaft tibia fibulaDD : CF of right shaft tibia isolated

2nd AssessmentCF of right shaft tibia fibula oblique type.

AO: 42.B2VAS : 4ISS : 9Tscherne : 2PlanDefinitive Treatment :ORIFTHANK YOU