EMERGENCY REPORT RSO Prof Dr R Soeharso Solo Thursday, April 30th, 2015 Consultant : dr. Tito Sumarwoto, Sp.OT(K) dr. Bayuaji dr. Zen dr. Harry dr. Sidiq

Emergency Room Patient Inward patient No Identity Assesment Plan 1 Jilan 35 y.o 27 52 46 Burst fracture of 2nd Lumbar Vertebrae Frankel E Closed fracture of left middle third of clavicle comminutive Allman group I Consult to spine ORIF 2 Agus 18 y.o 27 52 45 Closed fracture of left sub trochanter Fielding I Closed posterior dislocation of left elbow Emergency Close reduction + slab 3 Sumartini 33 y.o 27 52 48 CF of right shaft tibia fibula oblique type. 2

Out No Identity Assesment Action Putri R 21 y.o 27 52 30 1. Putri R 21 y.o 27 52 30 Ligamentous injury knee (D) Kocher Slab Analgetic 2 Balqis 29 y.o 27 52 43 Contusio musculorum r. elbow (D) Arm sling 3 Kardi 12 y.o 27 52 44 Contusio musculorum r.antebrachii (S) Armsling 4 Lukman 11 y.o 27 52 40 CF Radius ulna distal third (D) Closered + LAC 3

VIP No Identity Assesment Plan - 4

Refuse for treatment No Identity Assesment Action 1. - 5

1st patient

IDENTITY Name : Agus Novrianto Sex : Male Age : 18 y.o Medical Record : 275245 Ward : PK

A: Clear, stable c-spine Primary Survey Male 18 y.o came to ER with chief complain pain on his left hip after MVA A: Clear, stable c-spine B: Spontaneous, thoracoabdominally, RR: 20 x/m C: HR: 90 x/m, BP : 120/65 mmHg D: GCS E4V5M6, isochoric pupil (3 mm/3 mm) E: T : 36,5 0C, lesion (+) look at physical examination 8

History Taking Chief Complaint : Pain on the left hip Present 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.

Abdominal : no abnormality Secondary Survey Head : no abnormality Neck : no abnormality Eyes : no abnormality Nose : no abnormality Ears : no abnormality Mouth : no abnormality Chest : no abnormality Abdominal : no abnormality Extremities : Lesion (+) look at physical examination 10

Physical Examination Left hip region : L : skin intact, swelling (+), bruising (+), deformity (+) exorotation, shortening (+) F : NVD (-), Tenderness (+) over proximal femur, Bryant triangle symmetric, (+), LLD : + 1 cm M : ROM hip and knee limited due to pain ROM ankle & toes full Left elbow: L : skin intact, swelling (+), deformity (+) posterior angulation F : NVD (-), Tenderness (+) around the elbow, Hueter line is broken M : ROM elbow limited due to pain

1st Assessment Injury around the left hip DD CF of left sub trochanter femur CF of left intertrochanter femur Injury around left elbow DD posterior dislocation of left elbow Fracture dislocation of left elbow

1st Plan Analgetic Immobilization Laboratory examination X ray

2nd assessment Closed fracture of left sub trochanter Fielding I AO 31 - A3 Closed posterior dislocation of left elbow AO 2.3 – B2 Tscherne 1 ISS : 9 VAS : 5-6

2nd Plan Definitive treatment : CF left intertrochanter femur  ORIF CF left distal radius  Emergency Closed Reduction + slab

2nd patient

IDENTITY Name : Jilan Sex : Male Age : 35 y.o Medical Record : 275246 Ward : PS

A: Clear, stable c-spine Primary Survey Male 35 y.o, came to emergency room with chief complain pain on his lower back after MVA A: Clear, stable c-spine B: Spontaneous, thoracoabdominally, RR: 18 x/m C: HR: 98 x/m, BP : 120 / 68 mmHg D: GCS E4V5M6, isochoric pupil (3 mm/3 mm) E: T : 36,7 C, lesion (+) look at physical examination 24

Secondary survey Chief complaint : Pain on lower back Present 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.

Abdominal : no abnormality Secondary Survey Head : no abnormality Neck : no abnormality Eyes : no abnormality Nose : no abnormality Ears : no abnormality Mouth : no abnormality Chest : no abnormality Abdominal : no abnormality Extremities : Lesion (+) look at physical examination 26

Local Physical Examination Thoracolumbar 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 clavicle M : ROM hard to evaluated due to pain, ROM elbow, wrist and finger full

Neurological Examination Sensoric : normal Motoric : Reflex : Bulbocavernous reflex (+) Sacral sparring : (+) D S C5 5 C6 C7 C8 T1 L2 L3 L4 L5 S1

1st Assessment Injury around Thoracolumbar region DD : Compression fracture of thoracolumbar spine Burst fracture of thoracolumbar spine Fracture dislocation of thoracolumbar spine Closed fracture of left middle third clavicle

Plan Immobilization Analgetic X ray Laboratory examination

2nd Assessment Burst fracture of 2nd Lumbar Vertebrae Frankel E AO : 53.A3 Closed fracture of left middle third of clavicle comminutive Allman group I AO : 15. B3 VAS : 4-5 ISS : 9

Plan Definitive treatment Burst fracture  consult to Sub Spine Clavicle  ORIF

3rd patient

IDENTITY Name : Sumartini Sex : Female Age : 33 y.o Medical Record : 272465 Ward : PS

A: Clear, stable c-spine Primary Survey Female 33 y.o, came to emergency room with chief complain pain on the right lower leg after MVA A: Clear, stable c-spine B: Spontaneous, thoracoabdominally, RR: 18 x/m C: HR: 98 x/m, BP : 120 / 70mmHg D: GCS E4V5M6, isochoric pupil (3 mm/3 mm) E: T : 36,7 C, lesion (+) at the lower leg 39

Secondary survey Chief complaint : Pain on right lower leg Present 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.

Abdominal : no abnormality Secondary Survey Head : no abnormality Neck : no abnormality Eyes : no abnormality Nose : no abnormality Ears : no abnormality Mouth : no abnormality Chest : no abnormality Abdominal : no abnormality Extremities : Lesion (+) look at physical examination 41

Local Physical Examination Right lower leg region : L : skin intact, swelling (+), bruising(-), deformity (+), valgus angulation. F : NVD (-), Tenderness (+) at the shaft tibia fibula M : ROM knee and ankle hard to evaluate due to pain

1st Assessment CF of right shaft tibia fibula DD : CF of right shaft tibia isolated

2nd Assessment CF of right shaft tibia fibula oblique type. AO: 42.B2 VAS : 4 ISS : 9 Tscherne : 2

Plan Definitive Treatment : ORIF

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