Orthopedic Out Patient report

Shelly Sulvitri 030.08.226

TRISAKTI UNIVERSITY BEKASI GENERAL HOSPITAL

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I. Identity
Name Gender Age Address Occupation Religion First visit : An. E : Female : 7 years old : Bekasi Timur : : Moslem : 16th December 2012 (Emergency Unit)

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II. Chief complaint

crush injury in the left foot

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III.History Taking

yesterday afternoon at 5 o'clock, the patient was trying to climb a motorcycle that was parked, But motorcycle suddenly fell to the left 4th to his left toes exposed footstep of the motorcycle and the 4th toe was destroyed, including flip-flops that she was wearing. Then she taken by motorcycle to a nearby clinic by his parents then the clinics referred to the IGD RSUD Bekasi. In the IGD RSUD Bekasi to clean the wound, do amputation and bandage And from the IGD patient referred to control to poly orthopaedic RSUD Bekasi
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Transportation went to the hospital by motorcycle How far is the hospital? near (around 1.6 km) Brought to the emergency room First aid amputation of the 4th toe (left) and stitching

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History of the disease before

History of diabetes mellitus (-) History of trauma and operation (-) History of orthopaedy surgery (-)

Family History
History of bone disease (-) History of diabetes mellitus (-)

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IV. Physical examination

A. Vital Sign and Antropometry
General condition : looks mildly ill Consciousness : Compos Mentis, GCS E4M6V5 = 15

BP: HR: 98 x/minute RR: 24 x/minute T: 36,5 C

Weight Height BMI

: 20 kg : 120 cm : 15,3

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B. General Status
Head
Neck

Thorax
Abdomen

Extremities

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C. Local Status (Left Foot region)

Bleed (+) Laceration (+) Amputation distal interfalang joints at digiti 4th pedis sinistra with stitching in some parts.

Look

Feel

Warm on touch Pain on touch

Move
9

The patients range of movement no limited

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A.Radiology

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VI.Diagnosis
Crush injury of the left fore foot

Fracture transversum interfalangs medial 4th digiti pedis sinistra

Post Amputation of distal interfalangs joint 4th digiti pedis sinistra

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VII. Treatment

Conservative: - Antibiotic

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