preskes fraktur femur-2.doc
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preskes fraktur femur 1/3 distalTRANSCRIPT
Case Presentation
MALE 59 YEARS OLD WITH CLOSED FRACTURE
1/3 DISTAL OF LEFT FEMUR
Arranged by:
Esti Rahmawati S G0007064
Tutor:
dr. Tangkas Sibarani, SpOT, FICS
Clinical Department of Orthopaedic & Traumatology Sebelas Maret University
Hospital of Dr. Moewardi/ Orthopaedic Hospital of Prof. Dr. Soeharso
Surakarta
2012
LEGALY SHEET
Case presentation entitled “Male 59 Years Old with Closed Fracture 1/3
Distal of Left Femur” is arranged to fulfill the requirement of clinical department of
Orthopaedic & Traumatology Sebelas Maret University Hospital of Dr.
Moewardi/Orthopaedic Hospital of Prof. Dr. Soeharso, by:
Esti Rahmawati S G0007064
Has been approved by the case presentation tutor of the Orthopaedic
Hospital of Prof. Dr. Soeharso on May, 2012.
Tutor
dr. Tangkas Sibarani, SpOT, FICS
CASE PRESENTATION
I. ANAMNESIS
1. IDENTITY
Name : Mr. S
Age : 59 years old
Sex : Male
Address : Bungur V RT ¾ Punggawan Banjarsari
Medical record : 00219868
2. CHIEF COMPLAIN
Pain in his left upper leg when used for walking
3. PRESENT ILLNESS
Less than 2 days before hospital admission, patient got a traffic accident.
Suddenly a motorcycle crushed him. He fell to the left side with his feet hit the
asphalt. He couldn’t move his left leg and felt pain for walking. Then he taken
to Sangkal Putung but did not improved. Than he was taken to the Orthopaedic
Hospital of Prof. Dr. Soeharso, in order to get more treatment.
4. PAST HISTORY
History of previous trauma : denied
History of heart disease : denied
History of drug allergy : denied
Asthma history : denied
II. PHYSICAL EXAMINATION
1. PRIMARY SURVEY
Airway : Free
Breathing : Spontan, Thoracoabdominal, RR : 18 x/mnt
Circulation and control haemoragik : T : 110/70 mmHg, HR : 88 x/mnt
Disability : GCS E4 V5 M6, Light refleks (+/+)
Exposure : look local status
2. SECONDARY SURVEY
General condition : concious
Head : mesocephal
Eyes : pupil isokor (3mm/3mm), light refleks (+/+), redness
conjungtiva (-/-), jaundice sklera (-/-)
Nose : saddle nose (-/-), rhinorhea (-/-), deformity (-/-)
Mouth : malocclusion (-), maxillary shake (-), tooth loss (-)
Ears : bloody otorhea (-/-)
Neck : JVP was not increased, thyroid enlargement (-), an
enlarged lmpyh node (-)
Thorax : normochest, symetris, retraction (-), lession (-)
Cor
Inspection : ictus cordis invisible
Palpation : ictus cordis not strong enaugh to lift
Percussion: no abnormality
Auscultation: normal intensity of heart sound, reguler, murmur (-)
Pulmo
Inspection : retraction (-/-), chest development right = left
Palpation : fremitus right = left
Percussion : sonor/sonor
Auscultation : vesikular (+/+), addition sound (-/-)
Abdomen
Inspection : abdominal wall // chest wall
Auscultation : intestinal sound (+) normal
Percussion : thympani
Palpation : supel, pain (-)
Extremity
Motoric: upper extremity (5/5), lower extremity (5/x)
Sensoric: upper extremity (+/+), lower extremity (+/+)
III. LOCAL STATUS
Left femur region :
Look : swelling (+), shortening (+), skin intact, hematom (-).
Feel : NVD (-), the temperature of the skin in left upper leg is warmer than
around and right upper leg, pain (+),
Motion : ROM of coxae articulation and genu articulation are limited because
of pain. ROM ankle (+) full
LLD : 2 cm
IV. ASSESSMENT I
Suspect closed fracture of left femur
V. PLANNING I
Family motivation
X-ray of left upper leg in AP and lateral position
X-ray of pelvis in AP position
VI. ADDITIONAL EXAMINATION
X-ray of left upper leg in AP and Lateral position:
The x-ray of male 59 years old, was taken in Orthopaedic Hospital of Prof. Dr.
Soeharso.
The x-ray worth to read. Can be differentiated between soft tissue and bone.
Normal contrast and sentration. Swelling (+).
There is fracture line in 1/3 distal left femur with transversal configuration.
X-ray of pelvis in AP position :
The x-ray of male 59 years old, was taken in Orthopaedic Hospital of Prof. Dr.
Soeharso.
The x-ray worth to read. Can be differentiated between soft tissue and bone.
Normal contrast and sentration. No edema. Within normal limit.
VII. ASSESSMENT II
Closed fracture 1/3 distal of left femur
VIII. PLANNING II
Analgetic injection
complete blood check
immobilitation (Skin traction)
hospitalized and pro ORIF
IX. ADDITIONAL EXAMINATION
Complete blood check
Hb : 13,8 g/dl
AE : 3,73 x 106/μl
Hct : 41 %
AL : 10,4 x 103/µl
AT : 169 x 103 /µl
Blood type: B
PT : 13,4 detik
APTT : 27,7 detik
HBsAg : (-)
GDS : 84 mg/ dL
INR : 1,09
SGOT : 14 U/L
SGPT : 16 U/L
Ureum : 33 mg/dl
Creatinin : 0,71 mg/dl
X. PROGNOSIS
Ad vitam : good
Ad sanam : good
Ad fungsionam: good