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Luka Bakar E.C Air Panas Grade IIA 18 %: Oleh: Rizal Palero S.Ked PEMBIMBING: Dr. Jimmy Vareta, Sp. B

The document summarizes a case report about a 7-year-old male patient admitted to the hospital with chief complaints of difficulty moving his right knee for 15 days following a traffic accident. On examination, the patient's right knee showed signs of pain, tingling, and limited range of motion. Radiography revealed a suspected closed epiphyseal plate fracture of the right humerus. The patient was diagnosed with a Grade IIA 18% burn and the suspected fracture. He was treated non-operatively with antibiotics, analgesics, and therapy, and may require open reduction and internal fixation surgery. His prognosis for life, function, and healing was guarded.

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Rizal Palero
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77 views18 pages

Luka Bakar E.C Air Panas Grade IIA 18 %: Oleh: Rizal Palero S.Ked PEMBIMBING: Dr. Jimmy Vareta, Sp. B

The document summarizes a case report about a 7-year-old male patient admitted to the hospital with chief complaints of difficulty moving his right knee for 15 days following a traffic accident. On examination, the patient's right knee showed signs of pain, tingling, and limited range of motion. Radiography revealed a suspected closed epiphyseal plate fracture of the right humerus. The patient was diagnosed with a Grade IIA 18% burn and the suspected fracture. He was treated non-operatively with antibiotics, analgesics, and therapy, and may require open reduction and internal fixation surgery. His prognosis for life, function, and healing was guarded.

Uploaded by

Rizal Palero
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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BST

Luka Bakar e.c Air


Panas Grade IIA 18 %

OLEH : RIZAL PALERO S.Ked


PEMBIMBING : dr. Jimmy Vareta, Sp. B

DEPARTEMEN ILMU BEDAH


RUMAH SAKIT MUHAMMADIYAH PALEMBANG
FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH
PALEMBANG
2020
BAB II
LAPORAN KASUS
IDENTIFIKASI PASIEN
 Name : M. U
 Sex : Male
 Date of birth : 12 September 2012/ 7 years old
 Educational status : -
 Occupation : Student
 Marriage status : Not married
 Religion : Islam
 Tribe : Palembang
 Address : Dusun 4,Rt 004 nusa makmur. Air kumbang . Kab.
banyusasin
 Date of admission : Tuesday, 10 Februari 2020
Allonamnesa, 10 Februari
2020
 Anamnesis:

 Monday, 10 februari 2020 (alloanamnesis)

 Keluhan Utama :
 Sulit menggerakkan Dengkul kanan 15 hari SMRS

 Keluhan Tambahan :
 pain, tingling, difficult to move the Knee.
Allonamnesa, 10 Februari
2020
Riwayat Perjalanan Penyakit:
 15 days before admission, patient had a traffic accident. Patient’s
father was driving the motorcycle and patient is in front of his father.
Driving speed was 20 km/ jam and the road was slippery. Patient’s
motorcycle is slipped and brake suddenly then the motorcycle’s
handlebar falls on patient’s right leg, and right knee is pinched. Patient
complained of swelling, bruising. The patient was brought to the
alternative therapy. Patients leg was massaged 4 times but the
complaint is not relieved and cant be straighten, also patient feels
pain when doing activity
 Onset : Patient complained of pain on right knee since 15
days before admission
 Provocating : Patient feels more pain when walking or
doing activity
 Quality : Pain is like prickly pain
 Region : Pain is not radiated to other areas
 Severity : VAS 5
 Treatment :-
Riwayat Penyakit Terdahulu:

 Hipertension : Denied

 DM : Denied

 Asthma : Denied

 Heart Disease : Denied

 Kidney Disease : Denied

 history of surgery : Denied


Riwayat Penyakit Keluarga:
 History the same illness : (-)
 Another Illness :
 Hipertension : (-)
 DM : (-)
 Asthma : (-)
 Heart Disease : (-)
Physical Examination (28 December
2019)
 Pemeriksaan fisik
 Primary Survey
 Airway (A) : No. airway obstruction, bleeding (-), vomit (-), snoring
(-),gurgling (-), C-spine stable.
 Breating (B) : spontaneous, Chest wall symmetrical, RR: 22x/mnt
 Circulation (C) : warm extremity, CRT < 2”, pucat(-), HR: 92x/mnt,
regular, quality.
 Disability (D) :Sens: Alert, light (+/+), isokor
 Exposure (E) :
 Secondary Survey
 Status generalis
 Keadaan Umum : Tampak sakit sedang
 Kesadaran : Compos Mentis
 Blood Presure : 110/70 mmHg
 Heart rate : 92 x/menit, reguler, isi-tegangan cukup.
 respiration : 27x/menit,
 Temperature : 37 o C
 Height : 1 cm
 Weight : 41 kg
localized status:
Regio Brahialis sinistra
 Look: Hematom (-), Edema (+), Deformity
(-), scar (-), bleeding (-).
 Feel: warm (+), cracking (+)
 Move: ROM is limited
 NVD : Sensibility is good, radial artery
pulsation (+), quality is good, regular, CRT
< 2”
 
 Radiography of Humerus sinistra :
• Not in alignment
• Destruction/ fracture of left humerus 1/3 middle
• Soft tissue intact
• Susp. Closed Epipyseal plate fracture
Anatomi Regio Genu
 
Diagnosis Banding

 Luka Bakar e.c Air Panas Grade IIA 18 %

 Luka Bakar e.c Paparn Api Grade IIA 18 %

 Luka Bakar e.c Sengatan Listrik Grade IIA 18 %


Diagnosis Kerja

Susp. Closed Epipyseal plate fracture


Penatalaksanaan
 A. Non operatif
 a. Medikamentosa
 • Antibiotik
 • Analgetik
 • TT
 b. Non medikamentosa
 • Edukasi pasien tentang sakit
yang dialami pasien
 B. Operatif
 Open Reduction Internal Fixation
(ORIF) Plat and Scrrew
Prognosis
 Quo ad Vitam : Dubia ad Bonam
 Quo ad Functionam : Dubia ad Bonam
 Quo ad Sanationam : Dubia ad Bonam
Thank You

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