Patient Identity

• Name : Odez Akbar Osagi Sinaga

• Age : 19 years old
• Sex : Male
• Address : Kuta Alam, Banda Aceh
• MR : 1-16-17-08
• Phone : 082277913094
• Admission time : 09.53 WIB
 Time Response
Date/hour Examin Laboratory Radiology Hour Date/ DPJP
patient ation Examination Examination of Diag hour
came to ER hour nostics patient
Send Result Send Result out
from ER
13/02/2018 10.00 10.30 12.00 10.45 11.15 11.30 13/02/20 Dr. dr
09.53 WIB WIB WIB WIB WIB WIB WIB 18 Azharuddin
Sp. OT K-
18.00 Spine
WIB
Chief Complaint:
Lacerated wound at the left ankle

Present illness history

The patient came to Zainoel Abidin Hospital
emergency room with a chief complaint of lacerated
wound at the left ankle for an hour.
• Initially he was riding motorcycle and suddenly he slipped and fell off
to the asphalt, and he felt weakness and difficulty walking.
• There was no active bleeding.
• There were no history of decrease of consciousness, nausea and
vomiting.
 Physical examination
Primary Survey
• Air Way : Clear
• Breathing : Spontaneous, 20 breaths/minute

Left
Right haemithorax
haemithorax
Inspection Symmetrical, there was no deviation of trachea, JVP in normal limit.
Palpation Emphysema Subcutaneous (-) Emphysema Subcutaneous (-)
Percussion Sonor Sonor
Auscultation Vesicular, ronchi (-), wheezing (-) Vesicular, ronchi (-), wheezing (-)

• Circulation : BP : 110/70 mmHg, Pulse: 90

beats/minute
• Disability : GCS E4M6V5: 15
Exposure
L/S at the left ankle
• Look : Lacerated wound (+) with size 3 cm x 0,5 cm irregular
edge, tendon exposure (+), active bleeding (-)
• Feel : Pain (+), NVD (-), Thompson’s test (+)
• Move : ROM limited
Secondary Survey
Head  in normal limit
Neck  in normal limit
Thorax  in normal limit

Left
Right haemithorax
haemithorax
Inspection Symmetrical, there was no deviation of trachea, JVP in normal limit.
Palpation Emphysema Subcutaneous (-) Emphysema Subcutaneous (-)
Percussion Sonor Sonor
Auscultation Vesicular, ronchi (-), wheezing (-) Vesicular, ronchi (-), wheezing (-)

Abdomen  in normal limit

Pelvic  in normal limit
Upper extremity  in normal limit
Lower extremity 
L/S at the left ankle
• Look : Lacerated wound (+) with size 3 cm x 0,5 cm irregular edge, tendon
exposure (+), active bleeding (-)
• Feel : Pain (+), NVD (-), Thompson’s test (+)
• Move : ROM limited
Assessment:
• Total ruptured of the achilles tendiny of left
ankle.
Management
• Stop oral intake
• IVFD Rl 20 drips/minute
• Cefazoline inj 1 g
• Ketorolac inj 30 mg
• Tetagam inj 250 IU
• Laboratory examination
• Radiology examination
Laboratory Examination
• Hemoglobin : 14.1 gr/dl
• White Blood Count : 8.600/mm3
• Platelets : 291.000/mm3
• Hematocrit : 38 %
• PT/APTT : 11.0’/28.6’
Radiology examination

Left ankle Ap/Lateral

In normal limit
Diagnose
Total ruptured of the achilles tendiny of left ankle.
( ICD 10 S86.011 ).

Consult to orthopedic division:

• Debridement + repair ruptured of tendiny emergency
Operative Report
• Performed debridement with normal saline +
peroxide + povidone iodine
• Identification of Achilles tendiny
• Performed repair Achilles tendiny with Krackow
technique with propylene 1.0
• Performed foreslab
Diagnose Post Operative
Total ruptured of the achilles tendiny of left ankle
post debridement + repair rupture tendiny
(ICD 10 S86.011 ).
 Follow up

Date S O
14/02/2018 Pain Vital sign
(+) • General Condition :
POD 1 good
• BP : 110/70 mmHg
Raudah 7 • HR : 86 x/minute
• RR : 20 x/minute
• Temp : 37,1oC
A P
Post debridement + • IVFD Rl 20
repair rupture tendiny drips/minute
due to: • Inj. Cefazoline 1 g/12
hours
• Inj. Ketorolac 30
Total ruptured of the mg/8 hours
achilles tendiny of left • Free diet
ankle (ICD 10 S86.011
).

S/L at the left ankle Planning :

• Wound care
L : gauze dry, foreslab (+)
F : Pain (+), NVD (-)
M : ROM limited