SECONDARY SURVEY (at 00.00)

CLOSED FRACTURE OF LEFT TIBIAL PLATEAU SCHATZKER VIPATIENTS IDENTITYName:Mr. KTAge:43 years oldAdmitted:April 10th 2014Registration :658646AUTOANAMNESIS

Suffered since 5 hours before admitted to Dr. Wahidin Sudirohusodo hospital.Patient jumped 2 meters-high out from a ship, and landed with both his feet stepped on the ground. The patient could stand for a moment, and then felt pain at his left leg and fell down.History of unconsciousness (-), vomiting (-)Prior treatment at Akademis Hospital

Chief Complain : pain at left legPRIMARY SURVEYAirway:Clear, patentBreathing:RR 20 x/min, symmetric, spontaneous, thoracoabdominal type.Circulation:BP 120/70 mm/Hg, HR 88x/min, regular, strongDisability:GCS 15 E4V5M6, pupil isochor, diameter 2.5mm/2.5mm, light reflex (+/+)Exposure:36.7 C (axillary)SECONDARY SURVEYLeft Leg RegionLook:Deformity (+), swelling (+), hematoma (-), wound (-), shiny skin (-)Feel:Tenderness (+), NVD: sensibility is good, dorsalis pedis artery and tibialis posterior artery are palpable, CRT