STATUS PASIEN

BAGIAN ORTHOPEDIRUMAH SAKIT UMUM ANUTAPURA PALU

Nama : Sy. Rugaiyah AlkaffStambuk : 09 777 037Pembimbing Klinik : dr. Sri Sikspriani C.H, SpOT

PROGRAM STUDI PENDIDIKAN DOKTERFAKULTAS KEDOKTERANUNIVERSITAS ALKHAIRAATPALU2015

I. IDENTITYName : FebriansyahDate of Examination : 27-01-2015

Age : 7 years oldTime : 07.00 p.m

Adress : Labean, Pantai BaratHospital : Anutapura

II. GENERAL CONDITION Moderate sickness Vital Sign : BP : 90/70 mmHg HR : 94 x/second RR : 22 x/second T : 36,5oC

III. ANAMNESIS Chief complaint : Two legs are broken due to traffic accident since 10 hours ago at 09.00 a.m Trauma mechanism : This patient was collided by motorcycle when he was playing at roadside. Suddenly a motorcycle with high run come from his back and then collided the patient and made him throw to the front. After incident the patient still concious but he could not walk, no head injury, no nausea and vomit. Urine output and defecate is normal.

IV. PHYSICAL EXAMINATION Look : a. Frontal region : excoriation wound sized 2 cm x 1 cmb. Left temporal region : excoriation wound sized 3 cm x 1 cmc. Nasal region : excoriation wound sized 4 cm x 2 cmd. Orbicularis oris region : excoriation wound sized 1 cm x 1,5 cme. Mental region : seen sutured wound the long sized 3 cm, excoriation wound sized 6 cm x 3 cmf. Cruris region : excoriation wound with the circle shape sized 2 cm x 3 cm. Bone expose (-), muscle expose (-), wound side irregular and wound clean. Seen sutured wound and active bleeding (+) of right limb lower. g. Left thight region : swelling (+), deformity (+) Feel :a. Facial region Tenderness (+) Swelling (+) Deformity (+) Skin colour : hiperemis Crepitation : difficult to be evaluated Scar (-) Active bleeding (-) Skin temperature : same with arround it

b. Left thight region Tenderness (+) Swelling (+) Deformity (+) Skin colour : same with arround it Crepitation : difficult to be evaluated Scar (-) Active bleeding (-) Skin temperature : same with arround it

c. Right leg region Tenderness (+) Swelling (+) Deformity (-) Skin colour : same with arround it Crepitation : difficult to be evaluated Scar (-) Active bleeding (-) Skin temperature : same with arround it

ROM :a. Hip joint bilateral : difficult to be evaluated due to painb. Knee joint : difficult to be evaluated due to painc. Ankle joint : difficult to be evaluated due to pain

NVD :a. Rigt lower limb Pulse of dorsalis pedis artery : adecuate Pulse of tibialis anterior : adecuate CRT : 2 second Sensibility : normal Acral : warm, colour pinkishb. Left lower limb Pulse of dorsalis pedis artery : adecuate Pulse of tibialis anterior : adecuate CRT : 2 second Sensibility : normal Acral : warm, colour pinkish

V. TREATMENT MODALITIES Laboratory : whole blood X-Ray : Pelvis AP, Left femur AP, Right cruris AP / lateral

VI. DIAGNOSESuspect close fracture of left femur + close fracture of right 1/3 proximal tibia et fibula.

I. IDENTITYName : Muh. PrayudaDate of Examination : 27-01-2015

Age : 10 years oldTime : 05.00 p.m

Adress : Jln. Munif Rahman No.22Hospital : Anutapura

II. GENERAL CONDITION Moderate sickness Vital Sign : BP : 100/70 mmHg HR : 88 x/second RR : 20 x/second T : 36o C

III. ANAMNESIS Chief complaint : The patient come to the hospital due to air gun shut wound. Trauma mechanism : Shut wound on the second finger of his right hand occured at 04.00 p.m when he was playing air rifle with his friend aged younger than him. Patient no loss of consciousness, no nausea and vomit. Urine output and defecate is normal.

IV. PHYSICAL EXAMINATION Right second finger of hand Look : Laceration wound in the volar side, sized 1,5 cm circle shape, swelling (+), scar (-), deformity (-), active bleeding (+) Feel : Tenderness (+), Crepitation difficult to be evaluated ROM : MCP joint, PIP joint and DIP joint difficult to be evaluated due to pain NVD : Pulse of radial and ulnar artery adecuate CRT : 2 second Sensibility : normal Acral of second finger right hand : warm, skin colour pinkish

V. TREATMENT MODALITIES X-Ray : Right hand AP / Oblique

VI. DIAGNOSEV. sclopetorum of second finger of right hand.