Mr Sul 4d5k2r

1. Mr. Sulaiman/ 40 y.o/MR 1.43.50.99 itted on July 27th 2019 at AM Chief Complain : pain in his left thigh History : He Complained pain in his left thigh since 1 hour before itted. Initially he cutting wood use grinder and then its slips and hit his thighs. From his wound was bleeding about 1/2 glass mineral water. And then he immediately wrapped his wound with cloth and then bleeding stops. He was taken to the Islamic Hospital for further treatment for his wound, because of rupture from his muscle and then he was refered to Ulin Hospital. He never complained nausea (-), vomiting (-), headache (-) blood from the nose and ears (-).

History of Past Illness : Trauma (-), HT (-), DM(-), History of Family Illness : -

Primary Survey • Airway : • Clear, without C-Spine control

• Breathing : • Lesion (-), symmetrical movement, RR : 20x/minute (regular), vesicular breath sound, Rh (-/-) Wh (-/-). SpO2 : 99% without O2

• Circulation : • HR : 80x/minute (regular, strong pulse), BP : 130/90 mmHg, warm extremities, no active bleeding.

• Disability : • GCS E4V5M6, pupil equal 2 mm/2 mm, direct light reflex (+/+), lateralization (-)

Secondary Survey • Allergy • Medication • Past Illness • Last Meal • Environment

: (-) : (-) : (-) : 12.00 : Banjarmasin

Head/Neck

Chest

Abdomen

Extremities

• pale conjungtiva (+/+), sclera icteric (-/-), pupil equal 3mm/3mm, light reflex (+/+)

• I : symmetric respiratory movement, retraction (-), bruise (-) • P : symmetric vocal fremitus • P : sonor at all lung fields • A : vesicular breath sound, rhonchi (-), wheezing (-) • I : distension (-), flat, mass (-), venectation (-) • A : bowel sound (+) 6-8 x/minute • P : Tenderness (-), defans muscular (-). liver, spleen, mass not palpable • P : tympani (+)

• warm extremities in all regio, parase (-), edem (-), CRT <3 s

Clinical Picture

X-Ray Thorax

Femur AP/LAT X-Ray

Laboratory Finding 27/07/2019 Examination

Result

Normal Value

Hemoglobin

13,7

12,00-16,00 g/dl

Leukosit

9,9

4,0-10,5 ribu/ul

Eritrosit

7,28

3,90-5,50 juta/ul

Hematokrit

39,3

37,00-47,00 vol%

Trombosit

235

150-450 ribu/ul

RDW-CV

18,9

11,5-14,7 %

MCV

54

80,0-97,0 fl

MCH

18,8

27,0-32,0 pg

MCHC

34,9

32,0- 38,0 %

Gran %

75,8

50,0-70,0 %

Limfosit %

14,4

25,0-40,0 %

MID %

7,9

4,0-11,0 %

Gran #

7,47

2,50-7,00 ribu/ul

Limfosit #

1,42

1,25-4,0 ribu/ul

MID #

0,78

Examination

Result

Normal Value

PT

10,4

9,9-13,5 detik

INR

1,02

APTT

22,4

22,2-37,0 detik

GDS

117

<200

Ureum

26

10-50 mg/dl

Creatinin

1,04

0,7-1,4 mg/dl

Natrium

140

135-146 mmol/l

Kalium

4,1

3,4-5,4 mmol/l

Chlorida

105

95-100 mmol/l

Diagnosis Vulnus Scissum a/r Femoralis Sinistra + Rupture Musculus Rectus Femoris Sinistra

Management Treatment in ER : • IVFD RL 20 dpm • Ceftriaxone injection 2x1 gr IV • Ketorolac injection 3x30 mg IV • Ranitidine injection 2x50 mg IV • Inj Tetagam 250 ui IM

Consult to Orthopaedic Surgery : • Debridement and repair musculus