PATIENT’S STATUS

Room number : B1221

Day/date of admission : 5th September 2019
Medical record number : 09.73.42
PATIENT’S IDENTITY

Name : Mr. K.T.F.

Sex : Male
Date of birth : 14th April 1952
Age: 67 years old
Nationality : Indonesia
Religion : Buddhist
HISTORY TAKING
Presenting complaint:
 Pain on left hip joint
History of presenting complaint :
 Patient came to Royal Prima ER on 5th September 2019 with the complaints of
pain on his left hip joint. Having a history of falling down from staircase
around 2 weeks ago.
 Claimed that he wasn’t able to move his left leg as the pain worsen as he
moves after the injury.
Past history : Hypertension
Drug history : Aspilet
Family history : -
PHYSICAL EXAMINATION

Vital sign
BP : 151/104mmHg
RR : 20x/i
HR : 82x/i
T : 37o C
GCS : 15
O2 saturation : 99%
PHYSICAL EXAMINATION

Head : Normocephalus
Eyes : Pupil Isokor, Icteric Sclera (- / -), Anemic Conjunctiva (- / -),
Light Reflex (+ / +)
Ears : normal
Nose : normal
Mouth : normal
Neck : Lymph Node Enlargement (-)
PHYSICAL EXAMINATION
Thorax :
 Anterior
 Inspection : symmetrical fusiform
 Palpation : symmetrical
 Percussion : resonance
 Auscultation : vesicular, normal breath sound
 Posterior
 Inspection : symmetrical fusiform
 Palpation : symmetrical
 Percussion : resonance
 Auscultation : vesicular, normal breath sound
Heart :
 Inspection : ictus cordis not visible
 Palpation : ictus cordis not palpable
 Percussion : normal
 Auscultation : normal S1, S2, murmur (-), gallop (-)
PHYSICAL EXAMINATION
Abdomen
 Inspection : symmetry, spider nevi (-), ascites(-)
 Auscultation : normal peristaltic sound
 Palpation : normal, no tenderness
 Percussion : tympanic

CNS
 Consciousness : compos mentis
 GCS : 15
 CN functions : normal

Genitalia : not examined

PHYSICAL EXAMINATION
Extremities
 Upper extremities
 Look : normal
 Feel : normal
 Move : normal

 Lower extremities
 Look : right lower extremities are normal. Left lower extremities: swelling
around the hip joint, skin looks normal, left leg are shorter than the right leg.
 Feel : tenderness felt on left hip joints
 Move : left hip stiffness, ROM is diminished
DIAGNOSIS

Temporary diagnosis :
Closed fracture of (left) neck of femur
Further investigation :
X-ray (AP view) & thorax
CBC
ECG
LABORATORY RESULT

Hematology
No. Test Result Unit Normal Range
1 Hemoglobin 13.1 g/dL 13.5 – 15.5
2 Leukocyte 13.68 103/μL 5 – 11
3 Platelets 31 103/μL 150 – 450
4 Hct 38.6 % 30.5 – 45.0
5 Erythrocyte 4.16 106/mm3 4.5 – 6.5
6 MCV 92.9 μm3 75.0 – 95.0
7 MCH 31.4 pg/cell 27.0 – 31.0
8 MCHC 33.8 g/dL 32.0 - 34.0
LABORATORY RESULT

Hematology
No. Test Result Unit Normal Range
9 RDW 13.5 % 11.50 – 14.50
10 PDW 55.9 fL 12.0 – 55.0
11 MPV 8.6 fL 6.50 – 9.50
12 PCT 0.28 % 0.10 – 0.50
13 Eusinophil 1.7 % 1–3
14 Basophil 0.2 % 0–1
15 Monocyte 4.3 % 2–8
16 Neutrophil 82 % 50 – 70
17 Lymphocyte 11.2 % 20 – 40
18 LUC 0.5 % 0-4
IMAGING (PRE-OPERATIVE) 23/8/2019
TREATMENT
Plan : hemiarthroplasty (cemented)
Actions :
 Patient placed in lateral decubitus position
 Anaesthetic procedure (spinal)
 Disinfection & draping
 Posterior approach incision
 Femur replacement component identification
 Hemiarthroplasty 48”
 Wound washing, drainage placement
 Wound closure
IMAGING (POST-OPERATIVE) 6/9/2019
POST-OPERATIVE ASSESSMENT
Definite diagnosis
 Closed fracture of (left) intertrochanteric femur
Treatment
 Viccyline
 Ketorolac
 Ranitidine
Education
 Preventing post-operative infection
 Wound hygiene control
 Changing wet bandages
 Early ambulation & physiotherapy
POST-OPERATIVE ASSESSMENT

Complications :
Periprosthetic fracture
Aseptic loosening
Unexplained persistent hip pain
Deep & superficial wound infection
Dislocation
Poor mobility
Lower limb muscle wasting
Leg length discrepancy
Thromboembolic disease
Intraoperative death