EMERGENCY REPORT

RSO Prof Dr R Soeharso Solo

Thursday,

April 30th, 2015

dr.
dr.
dr.
dr.

Bayuaji
Zen
Harry
Sidiq

Consultant : dr. Tito Sumarwoto, Sp.OT(K)

Emergency Room Patient

Inward patient
No

Identity

Jilan 35 y.o
27 52 46

Agus 18 y.o
27 52 45

Assesment
Burst fracture of 2nd Lumbar
Vertebrae Frankel E

Sumartini 33 y.o
27 52 48

Consult to spine

Closed fracture of left middle third

of clavicle comminutive Allman
group I

ORIF

Closed fracture of left sub

trochanter Fielding I

ORIF

Closed posterior dislocation of left

elbow
3

Plan

CF of right shaft tibia fibula oblique

type.

Emergency Close
reduction + slab

ORIF

Out
No

Identity

Assesment

Action

1.

Putri R
21 y.o
27 52 30

Ligamentous injury knee (D)

Kocher Slab
Analgetic

Balqis
29 y.o
27 52 43

Contusio musculorum r.
elbow (D)

Arm sling
Analgetic

Kardi
12 y.o
27 52 44

Contusio musculorum
r.antebrachii (S)

Armsling
Analgetic

Lukman
11 y.o
27 52 40

CF Radius ulna distal third

(D)

Closered + LAC
Analgetic

VIP
No

Identity

Assesment

Plan

use for treatment

No

Identity

Assesment

Action

1.

st

patient

IDENTITY

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

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

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.

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

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

nd

Plan

Definitive treatment :
CF left intertrochanter femur ORIF
CF left distal radius Emergency
Closed Reduction + slab

nd

patient

IDENTITY

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

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

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.

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

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 :

C5

C6

C7

C8

T1

L2

L3

L4

L5

S1

Reflex :
Bulbocavernous reflex
(+)
Sacral sparring : (+)

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

nd

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

3 patient
rd

IDENTITY

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

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

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.

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

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

nd

Assessment

CF of right shaft tibia fibula oblique type.

AO: 42.B2
VAS : 4
ISS : 9
Tscherne : 2

Plan
Definitive Treatment :
ORIF

THANK YOU