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 Age Sex Address Medical record 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 couldnt 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 History of heart disease History of drug allergy Asthma history : denied : denied : denied : denied : Mr. S : 59 years old : Male : Bungur V RT Punggawan Banjarsari : 00219868

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 Head Eyes Nose Mouth Ears Neck Thorax 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 (-/-) : concious : mesocephal : pupil isokor (3mm/3mm), light refleks (+/+), redness conjungtiva (-/-), jaundice sklera (-/-) : saddle nose (-/-), rhinorhea (-/-), deformity (-/-) : malocclusion (-), maxillary shake (-), tooth loss (-) : bloody otorhea (-/-) : JVP was not increased, thyroid enlargement (-), an enlarged lmpyh node (-) : normochest, symetris, retraction (-), lession (-)

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 Feel Motion : swelling (+), shortening (+), skin intact, hematom (-). : NVD (-), the temperature of the skin in left upper leg is warmer than around and right upper leg, pain (+), : 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 AE Hct AL AT PT APTT X. PROGNOSIS Ad vitam Ad sanam : good : good : 13,8 g/dl : 3,73 x 106/l : 41 % : 10,4 x 103/l : 169 x 103 /l : 13,4 detik : 27,7 detik HBsAg GDS INR SGOT SGPT Ureum : (-) : 84 mg/ dL : 1,09 : 14 U/L : 16 U/L : 33 mg/dl

Blood type: B

Creatinin : 0,71 mg/dl

Ad fungsionam: good