Sunday, March 10th, 2013

Name

: Mr. R
Age
: 17 yo
Address : Lamongan
ID Number
: 750325
Hospital admission :
Wednesday , april 23th, 204

Chief complaint : left foot pain

History of present illness : this 17 years
male with a history pain on the left foot
pain after got motor accident. At the time of
accident, the patient was hit a motorcycle
sudden turn and fell to the right. She did
use a helmet.. PTA (-) and nausea (-).
Vomitting (-), headache (-), neck pain (-),
seizure (-).

 Past

medical history :

Hypertension (-)
Diabetes Mellitus (-)

Airway and Cervical control

Airway clear
C-Spine stable

Breathing

Symmetric chest wall movement (+)

RR 24x/mnt SpO2 99%
Sonor +/+
Ves +/+ Rh -/- Wh -/-

BP : 112/61 mmHg
Pulse : 92 bpm
Acral warm and dry to touch
CRT <2

Circulation and Bleeding Control

 Disability
GCS 456
Pupil round equal 3mm/3mm
LR +/+

Exposure
T : 36.4 C
Hematime left foot

 Left

food

Look : swelling (+), deformity shorter(+)

Feel : localized pain tenderness (+),

crepitation (-)
Move : ROM

 HEENT

: scleral icteric (-), pale conjunctiva

(-), within normal limit
Chest : Simetric-bilateral moves (+),
retraction (-)
Heart : s1s2 single
Lungs : bilaterally
Abdomen : flat (+), soft (+), tender (-),
Liver/Spleen unpalpable, flatulence (-),
bowel sounds (+) N
Extremities : acral warm and dry to touch,
swollen (-)

 Male 17 yo
Left foot pain
Pain after got a motor accident
Status localized left food : odem

+,

deformitas+, localized pain

tenderness (+), crepitation (-) ROM

Susp

CF cruris sinistra

X-ray cruris S AP/Lateral

DL
Faal Hemostasis

 IVFD Ringer Acetate 1500

Inj ketorolac 3 x 30 mg iv
DC
immobilization

cc/24h

of pelvic salk
Call orthopaedics and
traumatologist

 Diffcount : 2/0/68/19/11
HCT : 38.5 %
Haemoglobins : 13 mg/dl
Leukocytes : 7.200
Trombocytes : 525.000
BT : 230
CT : 730
Cl serum : 105 mmol/l
Kalium serum : 3.8 mmol/l
Natrium serum : 135 mmol/l
Urea : 38 mg/dl
Creatinine serum : 1.0 mg/dl

 General

appearance, Blood Pressure,

Pulse Rate, RR, temperature
pain

 Current

condition and diagnosis

Planning treatment
Prognosis and complication

Thank You..