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Name : Mr.S
Age : 36 years old
Address : Tanasa
Admission Date : Novembar, 5th 2017
DPJP : dr.Risal Alisih, Sp.OT
HISTORY TAKING
Main Complaint : pain at left leg
Anamnesis : (Autoanamnesis)
The patient reference Bayangkara with complaints pain at left leg since 10 hours ago after an traffic accident,
MOT
The patient riding a motorcycle, using a helmet with hihg speed. Mechanism traffic accident unknown.
History :
There was history sincop
There was no history of nausea and vomiting
There was no history blooding at mouth, nose,ear
There was no history alcohol consumption
There was history medical treatment with Bayangkara hospital is analgesic, H2RA.
Genera State : Conscious :
Moderate ill Composmentis
Airway Clear
BP 120/70 mmHg
Circulation HR = 98 x/min regular, strong
GCS 15 (E4V5M6), pupil isochors,
Disability : 2.5 mm/2.5 mm, light reflex +/+
Inspection : Deformity (-), hematom (+) in the region left orbita, swelling (+) in
the region left buccalis, wound (-)
Palpation : Tenderness (+)
LOCALIZED STATUS
Left Cruris
Inspection : Deformity (+), hematome (+), swelling (+) in the region of the left
cruris, wound (+) look vulnus laceratum at left genu region
(1cmx0,5cm).
Palpation : Tenderness (+), crepitation difficult to evaluation
ROM : Passive and active movement of genu joint and angkel joint was
limited due to pain.
NVD : Normal sensibility, palpable pulse in the left dorsum manus
artery, and CRT <2 seconds.
PLANNING
Blood routine test
Plain photo cruris left AP/Lat
CLINICAL FINDINGS
RADIOLOGY FINDINGS
DIAGNOSE
Analgetic
H2 reseptor antagonis