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STATUS PASIEN

BAGIAN ORTHOPEDI
RUMAH SAKIT UMUM ANUTAPURA PALU

Nama : Sy. Rugaiyah Alkaff


Stambuk : 09 777 037
Pembimbing Klinik : dr. Sri Sikspriani C.H, SpOT

PROGRAM STUDI PENDIDIKAN DOKTER


FAKULTAS KEDOKTERAN
UNIVERSITAS ALKHAIRAAT
PALU
2015

I. IDENTITY
Name : Febriansyah
Age : 7 years old
Adress : Labean, Pantai Barat

Date of Examination : 27-01-2015


Time : 07.00 p.m
Hospital : 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 cm
b. Left temporal region : excoriation wound sized 3 cm x 1 cm
c. Nasal region : excoriation wound sized 4 cm x 2 cm
d. Orbicularis oris region : excoriation wound sized 1 cm x 1,5 cm
e. Mental region : seen sutured wound the long sized 3 cm, excoriation
wound sized 6 cm x 3 cm
f. 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 pain
b. Knee joint : difficult to be evaluated due to pain
c. 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 pinkish
b. 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.

DIAGNOSE
Suspect close fracture of left femur + close fracture of right 1/3 proximal tibia

et fibula.

I. IDENTITY
Name : Muh. Prayuda
Age : 10 years old
Adress : Jln. Munif Rahman No.22

Date of Examination : 27-01-2015


Time : 05.00 p.m
Hospital : 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.

DIAGNOSE
V. sclopetorum of second finger of right hand.