STATUS PASIEN ORTHOPAEDI

IDENTITY
NAME : Sastro
AGE : 78 y.o
NO. MR :
ADDRESS : Pekalongan

CHIPS OF COMPLAIN : pain in the right hip

10 hour before admission to hospital, the patient fell off the floor when he w
Patient fell on the right side of the body and then patient felt pain in the righ
sad that he couldnt move the right leg because of the pain. then patient was
MECHANISM OF INJURY : emergency room of RSUD kraton after his son came home from work.

CAR ACCIDENT : (tanda centang)

MOTORCYCLE : (tanda centang)
BICYCLE : (tanda centang)
WALK : (tanda centang)
HOME : (tanda centang)
INDUSTRY : (tanda centang)

PHYSICAL EXAMINATION :
AIR WAY : patient can talk fluently -> airway clear, gargling (-), snorring (-)
BREATHING : RR 18x/min, regular and enough in depth
CIRCULATION : HR 73 x/ min, regular adequate tone and volume, BP 137/78 mmHg act

DISABILITY : Composmentis
GCS : 15

LOCAL STATUS : right hip

LOOK : deformity (+) skin redness (-) skin discontinuity with bone exposed
FEEL : pain (+), tenderness (+),same temperature with surrounding area, swe
MOVE : limited movement of right hip because of pain

CLINICAL PICTURE (PHOTO) :

ANTERIOR

:
MEDIAL :

LATERAL

:
POSTERIOR (IF POSIBLE) :

RONTGEN :
AP :
LAT

:
SPECIFIC (IF NEEDED) :
THORAX PA :
ECG (>30 YO) :
LAB :

WORK DIAGNOSTIC : Closed fracture collum femur dextra non complex

INITIAL PLAN / Tx : Ip Dx : S : -
O : thorax semierect, pelvic AP, cervical AP and lateral x-ray photo, bloo
PTT/PTTK,
Ip Rx :
IVID RL 20 drops per minutes
Inj Ketorolac 30mg/8 jam
Inj Ranitidine 50mg/12 jam
Ip Mx : General condition, vital signs, VAS
IP Ex : diagnosis planning and prognosis
Pro CITO debridement

DAILY FOLLOW UP
S : Pain post surgery (+)
O: General condition look mild ill, ROM is limited because of the pain
A: open fracture in the right clavicle
23/6/2018
23/6/2018
P: Pro thorax rontgen semierect position
Cefotaxime 3x1 gr Ketorolac 2x30mg

Gentamicin 2x80mg Asam tranexamat 2x500mg

THOPAEDI

l, the patient fell off the floor when he went to the bathroom.
ody and then patient felt pain in the right hip. and patient
eg because of the pain. then patient was taken to the
fter his son came home from work.

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clear, gargling (-), snorring (-)

n depth
one and volume, BP 137/78 mmHg active hemorrhage (-)

kin discontinuity with bone exposed (-).

perature with surrounding area, swelling (-)
ause of pain
ra non complex

rvical AP and lateral x-ray photo, blood routine analysis,

ns, VAS
gnosis

ROM is limited because of the pain

rolac 2x30mg Ranitidine 2x50mg
m tranexamat 2x500mg