ORTHOPEDIC ASSESSMENT

MAY 24 TH
2022
Rico, Ela, Randa, Andi, Waldi, Althof
PATIENT GOING TO
SURGERY
 1 Patient
st

Yunetri Roza/F/44 th/01.12.84.93

Entry from : Emergency Room

Entry Date : May 18th 2022
Ward : TC

Main complaint:
Pain in the waist since 4 months ago that comes and go
Current Illness History:
- Pain comes and go
- Pain radiates to buttocks and legs
- Pain in the waist and legs, especially when do strenuous activities-
- History of trauma (-)
- History of long cough (-)
Physical Examinations:
• General Appearance : Moderate Ill
• Consciousness : Composmentis, GSC 15
• Blood Pressure : 120/80 mmHg
• Heart Rate : 88 x/minutes
• Respiratory Rate : 19 x/minutes
• Temperature : 36,5 OC
• VAS :5

Eyes : anemic conjunctiva (-/-)

Thorax and Abdomen : within normal limits
Local Examination of Thoracal Posterior:
Look : deformity (-), lesion (-) hematoma (-) gibbus (-)
Feel : tenderness (+)
Move : limited ROM
ASIA’S Score:

Hip flexor 3/5

Knee ekstensor 4/5
Ankle dorsofleksi 4/5
Long toe ekstensor 4/5
Ankle plantar 4/5
Laboratory Examination on th 2022

Hemoglobin 13.8 mg/dL

Leukocytes 8.72/mm3
Platelets 398/ mm3
Hematocrit 40%
PT/aPTT 10.6/29.8 detik
Albumin 4.2 mg/dl
Na/K/Cl 143/3.6 /109 mmol/L
Diagnose :
Spondilolisthesis L5-S1 + canal stenosis L3,4,5

Plans :
Pro Decompression with stabilization
IVFD tutusol 8j/K
Inj. ceftriaxon 2x1gr
Parasetamol tab 3x500mg
Ranitidin 2x150mg
 2 Patient
nd

Januar / male/ 69 years old / 01.13.76.89

Admission : Emergency room

Date : May 20th, 2022
Ward : TC

Chief complaint
Pain at left hip joint since 12 hours before admission
Present Illness History
- Pain at left hip joint since 12 hours before admission
- Pain was felt continuosly
- Previously patient was carried on a motorbike, then when he wanted to
get off the patient fell from the motorbike with the left hip position
crashing into the asphalt
- Patient can't walk after the accident
- Micturition and bowel was normal
- No trauma in other part
- Patient had history of DM
Physical Examination

- General Appearance : Moderately illness

- Consciousness : CMC
- Blood pressure : 120/80 mmHg
- Heart rate : 86 x/minute
- Respiratory rate : 20 x/minute
- Temperature : 36,70C
- VAS : 5

Eyes : Conjungtive was not anemic

Thorax : Normal
Locally State:
Hip Joint sinistra region:
Look : Deformity (+) shortening, oedem (+)
Feel : Pain (+), acral was warm, NVD was good
Move : ROM limited by pain
AL TL
dextra 88 cm 83 cm
sinistra 85 cm 80 cm
Pelvis AP Rontgen
Ro Left Femur AP-Lat
Laboratory

Hb : 11,5 gr/dL
Leukosit : 11.000 /mm3
Trombosit : 345.000 /mm3
Ht : 36%
GDS : 133
Diagnose:
Closed fracture intertrokanter of left femur
Plan:
CRIF (PFNA) left femur
UNDER WENT SURGERY
 1st Patient
Annisa Hani/ F /16 th/ 01.13.15.38
Entry From : Polyclinic
Entry Date : May 21th 2022
Ward : Teratai

Diagnose
Torticollis Dextra

Surgery that has been done:

Release Torticollis
 2nd Patient
Ermiyati / F / 66 YO
Main Doctor : dr. Rizki Rahmadian, Sp.OT (K), M.Kes
Entry : Emergency Departement
Date : May 11th 2021
Ward : Aster

Diagnose :
• Closed frature of Intertrochanter left femur

Have Done Surgery :

• ORIF PFNA
Clinical Pictures
PreOp X-Rays
PostOps X-Rays
PostOps X-Rays
 3rd Patient
Mulyadi / LK / 44 YO
Main Doctor : dr. Rizki Rahmadian, Sp.OT (K), M.Kes
Entry : Emergency Departement
Date : May 20th 2021
Ward : Trauma Center

Diagnose :
• Patella Alta of Left Knee

Have Done Surgery :

• Recontruction of Left Patella
PreOp X-Rays
PreOp MRI
PreOp MRI
PostOps X-Rays