HOSPITAL KENINGAU MALE SURGICAL WARD

CASE PRESENTATION

BIODATA
Hospital : Hospital Keningau Ward : Male Surgical Ward Name : Mr. Y Register Number : HK00147659 Gender : Male Race : Dusun Job : Farmer Age : 25 years Date Of Admission : 01/03/2012

CHIEF COMPLAIN

Involved in Motor Vehicle Accident (lorry vs motorcycle). This patient was a rider of the motorcycle. He try to avoid a lorry and slided into a ditch. Sustained deep laceration from wound over Right knee area. No Loss of Concious, ENT bleeding, active bleeding elsewhere. Past Medical History : -NilPast Surgikal History : -NilFamily History : -NilSocial History : -Patient is heavy smoker and heavy alcoholic O&G History : -Nil-

GENERAL CONDITION

Patient is alert,pink,concious and unable to stand

PHYSICAL EXAMINATION
Temperature : 36.8 C Respiratory Rate : 24 Blood Pressure : 148/90mmHg Pulse : 75 / min SPO2 : 97% on air GCS : 15/15

HEAD

-No alopecia -No swelling and pale -Both eyes reactive with right eye pupil size 5mm and left eye pupil size 5mm -No jaundice

ENT
Ear : -No discharge -No bleeding Nose : -No epitaksis -No running nose -Sinus tenderness Throat : -No sore/ulser -Size of uvula and tonsil normal -No bleeding

Chest : -Lung : Clear, no rhonchi -Heart : Dual Rhythm No Murmur Abdomen : -No scar -Bowel sound normal (5-30 per minutes) -Resonance

INVESTIGATION :
Urea and Electrolytes
Types Urea Sodium Potassium Chloride Reading 5.1mmol/L 140.6mmol/L 4.82mmol/L 98.9 mmol/L Normal 2.0-8.3 mmol/L 135.0-150.0 mmol/L 3.10-5.10 mmol/L 95.0-110.0 mmol/L

Full Blood Count

Types
Haemoglobin Haematocrit White Blood Cell

Reading
11.0 g/dL 35.2 % 10.6x10^9 /v

Normal
13.5-18.0 g/dL 40.0-50.0 % 4.0-11.0 x 10^9/v

Malaria : No malaria parasite seen Culture & Sensitivity tissue : No Growth X-ray : Open Fracture Right Patella with Deep Laceration Wound

DIAGNOSIS
Early Diagnosis : Open Fracture Right Patella with Deep Laceration Wound Right Thigh Diagnosis Perbezaan : Comminated Tibial Platoon Fracture with Laceration Wound Right Thigh

PLAN/TREATMENT :
NBM with IVD 5paint (3paint Normal Saline 0.9% + 2paint Dextrose 5%) IM ATT stat IV Cloxaxillin 1g stat IM Tramal 1g stat Irrigation wound Wound debridement Open reduction Ext fixetor Steinment pin insertion

OPERATION

Prosedure : Wound debridement+Surgical Skin Grafting+Bone Grafting+Steinment Pin Insertion

POST OPERATION
Observation : Monitor vital sign Oral intake/IV fluid : Allow orally Analegestic : IM Tramal 75mg QID Others : IV Celuroxine 1.5mg TDS Daily Dressing Monitor Traction

MEDICATION
IV Cloxacillin 1g QID Tab Paracetamol 1g TDS IM Tramal 75mg QID IV Celuroxine 1.5mg TDS Cap Celebrex 200mg ON Tab Ascorbic Acid 100mg TDS Tab Ferrous Fumerate 200mg BD Tab Folic Acid 5mg OD Tab Vitamin Complex 1/1 OD