CHAPTER II

CASE REPORT
Identity
Name

: Mrs. R

MR

: 29 92 30

Age

: 59 years

Occupation: Housewife
Ethnicity : Makassar
History
The main complaints: pain and swelling in the right knee
History of present illness: patients entered hospital with complaints of
pain and swelling in her right knee suffered since four days ago, after falling
to slip on the floor. Patient falls with a right knee position in advance of the
floor, after which the patient complains can not lift her right leg. History of
previous treatment at disclaimed.
History of previous illness: hypertension (-), DM (-), nothing a history of
previous surgery
Family history of disease: not specific
PHYSICAL EXAMINATION
General state and Vital Signs:
General state: Looked ill being
GCS

: E4 V5 M6

primary Survey
Airway

: Patent

Breathing

: RR: 18 x / min, WHZ (- / -), Ronchi (- / -)

Circulation

: radial pulse 82x / min, mucosal skin within normal limits,

CRT <2 seconds

Generalists Status
Head
Form

: normocephal

Hair

: black, is not easily removed

Face

Inspection

: symmetric

Eye
Conjunctiva: not anemic
Sclera

: not icterus

Pupil

: isokor = 3mm-3mm, light reflex + / +

Ear
Form

: no deformity

Bleeding : - / Nose
Inspection

: no deformity and bleeding

Mouth and Throat

Inspection

: not visible cyanosis and hyperemia

Lymph Gland
Inspection

: not seem lymphadenopathy

Palpation

: no palpable lymphadenopathy

Pulmonary
I

: symmetric in a static state and dynamic

Pa : fremitus left = right

Pe : sonor
A : vesicular breath sounds, ronkhi - / -, wheezing - / Heart
I

: iktus cardiac invisible

Pa : iktus cordis palpable at RIC V 1 finger medial LMCS

Pe : heart boundaries within normal limits
A : pure heart sounds, regular rhythm, noisy (-)
Abdomen
I

: distention (-)

Pa : sociable, tenderness (-), rebound tenderness (-), liver and spleen not
palpable
Pe : tympani
A : bowel (+) normal

Status Localist
Regio Genu (D)
Look

: abrasions (+), swelling (+), deformity (+)

Feel

: palpation palpable gap in the patella dextra, tenderness (+), distal

sensibility (+),

dorsalis pedis arterial pulsation (+), capillary refilling

<2 "
Move

: ROM is limited because of pain (+)

DIAGNOSIS OF WORK
Patella Fracture Closed (D)
EXAMINATION SUPPORT
Radiological
X-ray AP, lateral: visible discontinuities patella bone on the right

X-ray Image Preoperative

Laboratory
Hb

: 12,9 g/dl

Htc

: 38,1 %

Leucosit

: 8.900/mm3
: 372.000/mm3

Trombosit
LED

: 50 mm/h

DIAGNOSIS
Patella Fracture Closed (D)
TREATMENT PLAN
General :
IVFD RL 18 tts / min
ORIF plan patella (D)
Specifically:
Cefoperazone 1 g / 24h (iv)
FOLLOW UP Post Op days I
S / Pain (+)
O / Regio genu (D)
Look : closed surgical wound with elastic verband (+)
Feel

: tenderness (+), distal neurovascular (+) normal, capillary refilling

<2 "
Move : limited ROM
A / Post ORIF fracture of the patella (D)
THERAPY
general:
IVFD RL 18 tts / min
Change verband 1x / day
specifically:
Sefoperazone 1 g / 24 hours / iv
Ranitidine inj. / 8 hours
Ketorolac inj. / 8 hours

FOLLOW UP Post Op-day II

S / post op pain
O / Regio genu (D)
Look : closed surgical wound elastic verband (+),
Feel

: tenderness (+), distal neurovascular (+) normal, capillary refilling

<2 "
Move : limited ROM
A / Post ORIF fracture of the patella (D)
Therapy
general:
aff infusion
Change verband 1x / day
specifically:
Levofloxacin 500 mg 1x/day
Na. diclofenac 2x1
Ranitidine 2x1