CASE REPORT

Friday, January 17th 2014

Team on duty:

I.

dr. Fachrul Razi

dr. Tugam Umar Beunot
dr. Rynaldi Andriansya
dr. Achmad
dr. Raja
dr. Jauhari
dr. Ronasky

Patient Identity
Name
Age
Sex
Address
CM
Hp
Patient came at

: Burhanudin
: 50 years old
: Male
: Teungoh, Alue Buket, Lhoksukon, Banda Aceh
: 98-74-48
: 085260395688
: 1.36 AM

II.

Chief Complaint:
Pain and difficulty to move of the right thigh.

III.

Present illness history

The patient came to emergency room Zainoel Abidin Hospital with a chief
complaint pain and difficulty to move of the right thigh since 3 days ago. The
patient was walking on the side walk and suddenly got hit by a car. He fell down
and his thigh hit to the street. History of unconsciousness and vomiting (-).

IV.

Physical examination
Primary Survey
Air Way
: Clear
Breathing : Spontaneous, 20 breaths/min
Circulation : BP: 140/70 HR: 84 beats/min
Disability : GCS E4M6V5: 15
Exposure :
L/S at the right clavicle
Look
: Wound (-), swelling (+), deformity (+)
Feel
: Pain (+), NVD (-)
Move
: ROM limited
L/S at the right thigh
Look
: Wound (-), swelling (+), deformity (+)
Feel
: Pain (+), NVD (-)
Move
: ROM limited

Secondary survey : There was no trauma at the other part of body

V.

Assessment:
Susp. Close Fracture of the right clavicle + Susp .Close fracture of the right
thigh

VI.

Management
Immobilization
IVFD RL 20 drips/min
Ketorolac inj.30 mg
Laboratory examination
Radiology examination

VII.

Laboratory result
Hb
White Blood Count
Platelets
Hematocrit
CT/BT
Blood glucose ad random

VIII.

: 10 gr/dl
: 14.300 /ul
: 414.000/ul
: 28 %
: 7/3
: 94 mg/dl

Radiology result
Thorax AP
Fracture of the of the midle third of the right clavicle
Right femur AP / Lat
Fracture subtrochanter of the right femur

IX.

Diagnose
Close subtrochanter fracture of the right femur (ICD 10 CM S72) + Close
fracture of the midle third of the right clavicle (ICD 10 CM S42)

X.

Consult to orthopedic surgery division:

o Hospitalized
o Figure of eight
o Skin Traction
o ORIF Elective

XI.
Date
20/1/2014,
Admission
day 3

Follow up
S
O
Pain (-) General Condition good
Blood presure 120/80
mmhg
Pulse 80 beat/minute
RR 20 breath/minute
L/S at the right thigh
Look: skin traction (+),

A
Close
subtrochanter
fracture of the
right femur (ICD
10 CM S72) +
Close fracture of
the midle third of
the right clavicle
(ICD 10 CM S42)

P
Immobilization
IVFD RL 30
drips/min
Ketorolac inj.30
mg/ 8 hour
Diet 1800 kcal