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Orthopedic In-Patient status

Endy Jutamulia 030.08.094 University of Trisakti Bekasi City General Hospital

I. Profile
Name

Gender
Age Address

Occupation Religion

Race
First visit
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: Ch. R : Male : 10 y.o : Jl. Kedondong 7 No.00 RT/RW 00 Kranji, Bekasi Barat : Student : Muslim : Javanese : Thrusday, 4 Oktober 2012

II. Chief Complaint


Left shoulder pain

III. Medical history (October 4th 2012)


Left shoulder pain
History of trauma: fell and hit the stair and injured the

shoulder Sideswipe injury on Left shoulder Hot packs as first aid on the spot Sent with familys car to ER; e. verband Shoulder X-ray were taken Seizure (-), fainted (-), Nosebleed (-), Ear bleeding (-)
Swelling (+), Bruise (+), Blood (-), Fever (-), Patient

often does sport (volleyball) History of DM (-),HT (-), Operation (-), Family (-),
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IV. Physical examination A. Vital Signs


Blood Pressure

Heart Rate
Respiration Rate Temperature General Condition Consciousness

: 120/80 mmHg : 80 x/m : 24 x/m : 36,5 oC : Tampak sakit ringan : Compos mentis, GCS E4M6V5 = 15

B. General Status
Head Neck Thorax Abdomen

Ekstremities

C. Status Lokalis Left Shoulder


Look :

Dressed with Figure of 8 Bandage Bruise (-) Redness (-) Swelling (+) Open wound(-)

Feel: Deformity (+) Tenderness(+) Warm (+) Move: Limited, painful ROM on flexion and adduction

V. Supporting examination
Xray3 Oktober 2012

VI. Diagnosis

Closed 2/4 middle of Left Clavicule fracture

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VII. Plan of Therapy


Complete lab examination
Pre-operative preparation Pro operation: ORIF Left Clavicule

(October 8th, 2012)

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Thank You

Operation report
Pre-operative: Patient had taken a complete lab examination and was consulted to pulmonologist and cardiologist The lab results were normal without contraindicating value Patient was declared fit for operation by pulmonologist and cardiologist Patient was given informed consent and planned to be operated on Monday, October 8th 2012, 08.00 09.00 Patient was admitted to Tulip Room for pre-operative preparation

During operation:
Patient was operated on Monday, Oktober 8th 2012, 08.00-

09.00 by Dr. dr. Fx Hendroyono, Sp.OT MARS


The diagnosis is closed complete fracture of left clavicule,

and the planned operation is ORIF with clavicule plate & screw:
Patient lied in supine position Aseptic & antiseptic were done Identification of fracture site Incision of site in S Shape Identification of fractured bone Isolation of fractured bone from surrounding tissues Reposition of fractured bone with reduction clamps Fixation of bone with clavicule plate and screw Site of operation is sutured layer by layer

Patient was admitted

to Tulip Room for post-operative observation


Xray for post-

operative assessment was taken on 17:20

1st day Post op (9/ X/ 2012)

Left Clavicule Fracture, Post Operation. Pen is positioned well and steady No Complicaiton is present from radiologic and laboratoric finding Patient was allowed to go home

Thank You

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