IDENTITY

Name : Child Kadek

Age : 1 year 8 months
Address : Konawe Selatan
Admission Date : January, 4th 2017
DPJP : dr. Rizal Alisi, Sp.OT
 HISTORY TAKING
 Main Complaint : Left leg pain

Anamnesis : (Autoanamnesis)
 Since 14 days ago after felt down from the swing

MOT
 The patient was playing the swing with her sister. When her sister pushed the swing, suddenly she felt
down. The position of felt wasn’t knew.

History :
 Syncope (-), ear and nose bleeding (-), vomiting (-),
PHYSICAL EXAMINATION

General State :
Moderate ill, conscious
Vital Sign :
BP : 90/50mmHg
RR : 27x/m regular, spontaneous, thoracoabdominal type
HR : 104x/m regular, adequately
T : 36,70c /axillary
 GENERALIZED STATUS

Head : Normally Chest : Normally

Face : Normally Abdomen : Normaly
Eyes : Normally Superior limb : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
LOCALIZED STATUS
Left femur

Inspection : Deformity (+), swelling (+), hematome (+), elongasi (+),

Shortening (-), Rotation (-), erythema (+)
Palpation : Tenderness (+)
ROM : Passive and active movement of genu joint and hip joint was
limited due to of pain.
NVD : Normal sensibility, palpable pulse in the right poplitea artery, and
CRT <2 seconds.
PLANNING

Plain photo left femur AP/Lat

Blood routine
DIAGNOSE

Close Fracture Medial Os

Femur Sinistra
 MANAGEMENT
Non Pharmacology Pharmacology

 Bed rest  IVFD

 Elevation right cruris  Antibiotics

 Compress cold water  Analgetics

 Imobilitation (spalak)  H2 reseptor antagonis

Consult to orthopaedic surgeon