Putri Status Rawat Jalan Poliklinik Orthopedi

8/11/2019 Putri Status Rawat Jalan Poliklinik Orthopedi

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II. CHIEF COMPLAINT

Limping

[email protected] September 2014


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III. HISTORY TAKING

Limping since 5 months ago due tosingle motorcycle accident, velocity >

80km/hour. As he fell, his left leg got

caught under the vehicle. Patientunabled to move his left leg right after.

Wound (-), unconsciousness (-)

retrograde amnesia (-), nausea /vomiting (- / -), helmet (+).



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No first aid at the accident site.Patient has immediately taken to the

bone shelter by motorcycle, treated

with massaging and traditionalsplinting method for 1 week

(inpatient). He came for check up

every 1 week for 1 month.

30 September 2014 [email protected] 5


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Three months after the accident,the pain subsided but the left leg

seemed shorter than other and

caused limping.



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IV.PHYSICAL EXAM

A. General data

Fully alert, mild illness

Vital sign:

BP :120/80 mmHg, HR:100 BPM,RR:18x/mins, normothermia

Gait:

Use crutch(Limping without crutch)



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B. Head to toe

Head :

Eye: Anemic (-) Jaundice (-)

Neck : Lymphadenopathy (-)

Thorax :

Pulmo : VBS right=left,Wheezing/rhonchi/rales(-)

Cor : heart sound reguler, murmur(-),

gallop(-)

Abdomen:

Flat, soft, bowel sound (+), tenderness(-), mass (-)

Extremity : see local data

[email protected]


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C. Local dataLeft leg region

Look :

Deformity

(-/+, LLD:2 cms)

Skin (intact/intact)

Discolorization

(-/redness on the medialaspect of lower leg)



10/1730 September 2014 [email protected] 10


Feel :

Warmth (-/+ on the medialaspect of lower leg)

Tenderness (-/+)Dorsalis pedis a. (regular,equal, normal pulsation)

CRT < 2


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Move :

Knee

Flexion (135/ 135) (N: 135)Extension (0/ 0) (N: 0)AnklePlantar flexion (55/30) (N: 55)Dorsiflexion (15/10) (N: 15)


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V.SUPPORTING EXAMINATION

LABORATORY

Pre op Post op

- -



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X-RAY

Knee not visualized


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VI.DIAGNOSIS

Malunion Fracture of the Left Tibia ICD X Code: S82.222P

Displaced transverse fracture of shaft of left

tibia, subsequent encounter for closed fracturewith malunion

Malunion Fracture of the Left Fibula

ICD X Code: S82.422P

Displaced transverse fracture of shaft of left

fibula, subsequent encounter for closed

fracture with malunion



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VII.TREATMENTS

A. Surgery Refracturation

ORIF

B. Physiotherapy



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30 September 2014 imel [email protected] 17

Putri Status Rawat Jalan Poliklinik Orthopedi

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