IDENTITY

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

RR 24x/min regular, spontaneous

Breathing symmetrical

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 +/+

Exposure T = 37,30 C (axillary)

GENERALIZED STATUS

Head : Normally Chest : Normally

Face : Normally Abdomen : Normaly
Eyes : Normally Lower limb : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
LOCALIZED STATUS
Left facialis

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

Open Frakture Segmental 1/3

Proximal Os Cruris Sinistra
 MANAGEMENT
Non Pharmacology Pharmacology

Bed rest IVFD

Imobilitation Antibiotic

Analgetic

H2 reseptor antagonis

Consult to orthopaedic surgeon

THANK YOU