identity

• Name : Mr. R K
• Age : 42
years old
• Sex : Male
Anamnesis

• Chief Complain : pain in right hip since 5 hours before admission

• History :
Patient come with pain in right hip after had a traffic
accident in Koenino area. The patient was riding a motor cycle
and hit by a car (bemo) from the front. He also can’t move his
right hip due to the pain. Helmet (-). The patient barely known
the mechanism of injury. Headache (-), nausea (-), vomit (-),
blood from nose and ear (-).
History of uncontrolled hypertension (+)
Primary survey
• A : clear and patent
• B : RR: 22 times/minute, chest expansion simetrical, VBS L=R
• C : Blood preasure : 140/100 mmHg , Pulse: 97 times/minute
reguler, CRT < 2 “,
• D : GCS E4M6V5, neurological deficit (-)
• E:
• Vulnus Excoriatum at left frontal regio
• Hematoma at palpebra superior
• hip flexion, knee flexion, posterior hip hematoma of the right hip
SECONDARY SURVEY
GCS : E4M6V5
Head : Vulnus Excoriatum at left frontal regio, Hematoma at palpebra
superior
Eye : pupil isokor (+/+), Direct and Indirect Ligth Reflex (+/+),conjungtive (-/-
), icteric scelra (-/-)
Ear : otorrhea (-/-)
Nose : blood clot (-/-), rhinorrhea (-/-)
Thorax : chest expansion bilateral symmetric, crepitation (-), mass (-). Vesicular
(+/+), ; ronchi (-/-), whezing (-/-).
• Abdomen
• Inspection : flat, distended (-), lesion (-),
• Palpation : tenderness (-), mass (-)
• Percussion : timpanyc sound (+)
• Auscultation : peristaltics (+) still normally

• Extremity: edema -/-, CRT< 2”

• localized Status: right hip
• Look: hip flexion, knee flexion, posterior hip hematoma
• Feel: tenderness (+)
• Move: limited ROM due to pain
X RAY PHOTO
assesment
• Vulnus Excoriatum at left frontal regio
• Hematoma at palpebra superior
• right hip joint Posterior dislocation
• Hyperglycemic
Planning
• IVFD RL 20 tpm
• Inj. Ketorolac 3x30 mg
• Pro close reduction hip under anesthesia
• GDP, GD2PP co interna