IDENTITY

Name : Mr. I
Age : 25 years old
Sex : Male
Adress : Watubangga
Admission : January, 21th 2018
Doctor in charge : dr. Muh. Rizal Alisi ,Sp.OT
 HISTORY TAKING
 Chief complain : swelling at left foot
 Anamnesis :
Suffer since 5 months ago. Patient not complaint about the pain. There was
pus out of the wound.
 History :
There was no history of fever
There was history of trauma
There was history of ORIF operation about 2 years ago, and then about 2
months later, the plate was broke
There was no history of postoperative control
There was history of medical treatment (+) antibiotic consumption
There were no history of Diabetic and Hypertension, there was hystory of
mental retardation
 PRESENT STATE
General Condition : Moderate illness
Composmentis (GCS 15 E4V5M6),
Lower Nutritional status

Vital Sign
BP : 130/80 mmHg
HR : 88x/minutes, reguler, strong
RR : 18x/minutes, thoracoabdominal type, symetrical
T : 36,9◦C axyllaris
 GENERALIZED STATE
 Head : Within Normal Limit
 Face : Within Normal Limit
 Eye : Within Normal Limit
 Nose : Within Normal Limit
 Mouth : Within Normal Limit
 Ear : Within Normal Limit
 Neck : Within Normal Limit
 Chest : Within Normal Limit
 Stomach : Within Normal Limit
 Upper Limb : Within Normal Limit
 Left Lower Limb : Localized state
 Right Lower Limb : Within Normal Limit
Localized state (left lower limb)

Cruris Sinistra
 Inspection: Deformity (+), hematoma (-), swelling
(+), wound (+), Pus (+)
 Palpation : tenderness (-)
 ROM :
 Active and passive motion of genu joint is hard
 Active and passive motion of ankle joint is good

 NVD : sensibility is good, pulsation of artery

dorsalis pedis is palpable (+), CRT ≤ 2 second.
CLINICAL FINDING
 PLANNING

Routine Blood Test

X-ray Cruris Sinistra Ap/Lat
X-Ray Cruris Sinistra Ap/Lat
 DIAGNOSIS
Chronic Osteomyelitis
at Left Cruris
 PHARMACOLOGY NON PHARMACOLOGY

 IVFD  Rest
 Education
 Analgetics injection
 Wound care
 Antibiotic injection
 H2RA injection

Consult Orthopedic surgeon

Thank You