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Name
Age
Sex
Date of admittance
MR Number
: MNA
: 30 years old
: Male
: 19th April 2015
: 708978
HISTORY
Chief Complaint
History of illness
accident.
History of unconsciousness (-), nausea (-), vomit (-).
PHYSICAL EXAMINATION
PRIMARY SURVEY
Airway
Breathing
Circulation
Disability
Environment
: Patent
: RR=20x/min, symmetrical, spontaneous, thoracoabdominal type
: BP=130/80 mmHg, P=82x/minute regular and strong
: GCS 15 (E4M6V5), light reflex +/+, isochoric pupil 2.5/2.5 mm
: Axillary temperature of 36.5oC
SECONDARY SURVEY
Left Knee Joint
Inspection : Deformity (+), swelling (+), hematoma (+), excoriated wound (+) at
Palpation
ROM
NVD
NVD
ALL
TLL
LLD
Left
80 cm
80 cm
CLINICAL PICTURE
RESULT
WBC
RBC
HGB
HCT
PLT
HbsAg
CT
BT
RADIOLOGICAL FINDINGS
Figure 4: Knee X-ray at AP and lateral aspect shows fracture of tibial plateau
Figure 5: Tibia and fibula X-ray at AP and lateral view shows fracture of tibial plateau
DIAGNOSIS
Closed fracture of left tibia plateau
Hemarthrosis left knee joint
MANAGEMENT
IVFD Ringer Lactat
Analgetic
Antibiotic
Apply long leg back slab at left lower limb
Elevation of left lower limb
Plan for ORIF
RESUME
A male, 30 years old suffered from the knee pain since 2 day before admitted to the
Wahidin Sudirohusodo Hospital due to accident.
From physical finding there are swelling, deformity, hematoma, excoriated wound at
anterior aspect of knee which same level as patella, tenderness, positive patellar
tapping and Ballotement sign at the left knee joint, active and passive motions of the
knee joints are limited due to pain and distal neurovascular within normal range.
From physical finding there are swelling, deformity, hematoma and tenderness at the
left leg region, active and passive motions of the knee joints are limited due to pain
and distal neurovascular within normal range.
From radiological findings at both knee and tibia x-rays, there is fracture at tibial
plateau.