Ibrahim_Assegaf femur fracture patient ot

Femur fracture

1. MORNING REPORT EMERGENCY ROOM WAHIDIN SUDIROHUSODO GENERAL HOSPITAL MAKASSAR May 19 th , 202 3 NB/LS/CT/EL

2. IDENTITY Name : Ibrahim Assegaf Age : 58 year s old / Male Admission : May 19 th , 2023 at 15.15 WITA Registration : 1021981 Status : JKN Phone Number : 082291007755

3. AUTOANAMNESIS (at 15.20) Suffered since 2 days before admitted to Wahidin Sudirohusodo hospital. Patient was walking when he fell down due to slippery floor. He fell to the left side. After the accident, the patient could not walk nor stand due to pain. Before the accident patient could stand and walk without aid. Patient was treated in Budi Agung Hospital in Palu for a day before sent home. Patient then came to Wahidin Sudirohusodo hospital for further treatment. There was history of trauma in 2013, patient’s right hand was broken due to accident when riding motorcycle. The patient then had surgery with plate and screw at right distal radius at Dr. Soetomo Hospital Surabaya There was history of going to bone setter once There was no history of hypertension There was no history of diabetes mellitus Chief Complain : Pain at left groin

4. GENERAL STATUS (at 15.25 ) Conscious / W ell-nourished Vital Signs: Blood pressure : 153/89 mmHg Pulse rate : 94 x/min Respiratory rate : 20 x/min Temperature : 3 6,5 C NR S : 3/10

5. CLINICAL FINDING (at 15.30 )

6. LOCAL STATUS (at 15.30 ) Left Groin L ook : Deformity (+), s welling ( + ) hematoma (-), Wound (-) Feel : Tenderness (+) Move : Active and passive movement of hip joint cannot be evaluated due to pain. Active and passive movement of knee joint cannot be evaluated due to pain. NVD : Sensibility is good. Pulsation of dorsalis pedis and tibialis posterior arteries are palpable. Capillary refill time < 2 seconds.

7. Leg Length Discrepancy RIGHT LEFT ALL 100 cm 98 cm TLL 92 cm 90 cm LLD 2 cm

8. RADIOLOGY FINDING (at 18.29 )

9. RADIOLOGY FINDING (at 18.31 )

10. L ABORATO RY FINDING (at 15.40) WBC : 12.7 x 10 3 / uL HGB : 13.4 gr/dL HCT : 36 % PLT : 241 x 10 3 / uL HbsAg : Non reactive PT : 9.8 seconds APTT : 25.9 seconds INR : 0.91 LED : 4 RBS : 129 mg/dl Ureum : 33 mg/dl Creatinin : 1.02 mg/dl ALT : 23 mg/dl AST : 24 mg/dl Sodium : 142 mmol/l Potassium : 4.3 mmol/l Chloride : 104 mmol/l

11. AO Classification AO Classification 31A1.2 IC MT1 NV1

12. DIAGNOSIS Closed fracture intertrochanter left femur AO Classification 31A3.1 IC MT1 NV1 Union distal right radius post ORIF plate and screw

13. MANAGEMENT IVFD Analge t ic Report to orthopaedic senior, advice : Apply skin traction with 3kgs of load at left lower limb Report to orthopaedic consultant, advice: Open reduction dynamic hip screw left femur

14. APPLIED SKIN TRACTION AT LEFT LOWER LIMB (3 kgs load)

15. THANK YOU

16. RADIOLOGY FINDING (at 18.27)

17. RADIOLOGY FINDING (at 18.36 )

18. CLINICAL FINDING (at 15.30 )

19. CLINICAL FINDING (at 15.30 )

20. CLINICAL FINDING (at 15.30 )

21. LOCAL STATUS (at 15.30 ) Right Forearm L ook : Deformity (-), s welling ( - ) hematoma (-), Scar Wound (+) as long as 3 cm Feel : Tenderness (-) Move : Active and passive movement of elbow joint within normal limit Active and passive movement of wrist joint within normal limit NVD : Sensibility is good. Pulsation of radialis and ulnaris arteries are palpable. Capillary refill time < 2 seconds.

22. RADIOLOGY FINDING ( at Budi Agung Hospital )