Ahmad Hisyam

Boy/12 y.o.
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 IDENTITY
Name : Ahmad Hisyam

Age : 12 years old/ Boy

Admission : January 15th, 2023 at 17.11 WITA

Registration : 484329

Status : JKN

Phone : 085255851692
Number
 AUTOANAMNESIS
Chief Complain : Pain at the left forearn
• Pain at the left forearm suffered since 1 hour before the hospital. Pain is felt continuously.
The pain is exacerbated when the patient moves his left arm. Pain is felt after the patient
falls with the left arm straight holding the patient's body. Shortly after the incident the
patient found it difficult to move his left arm because of the pain. After the incident, the
patient was immediately taken to the Wahidin Sudirohusodo Hospital
• There was no history loss pf concsiousness
• There was no history of projectile vomiting
• There was no history of hypertension and diabetes mellitus
• The patient is a student with right hand dominance
GENERAL STATUS

• GCS 15 (E4V5M6) / well nourished

• Vital Signs:
Blood pressure : 100/60 mmHg
Pulse rate : 82 x/min
Respiratory rate : 20 x/min
Temperature : 36,6 0C
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 LOCAL STATUS

Left forearm region

Look : Deformity (+) , swelling (+), hematoma (-), wound (-)
Feel : Tenderness (+)
Move : Active and passive movement of elbow joint could not be
evaluated due to pain
Active and passive movement of wrist joint could not be
evaluated due to pain
NVD : Sensibility is good, pulsation of radialis and ulnaris artery are
palpable. Capillary refill time < 2 seconds.
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LABORATORY FINDING

 WBC : 9.0 x103/ /mm3  RBS : 136 mg/dl

 HGB : 15.7 g/dL  SGOT : 29 U/L
 HCT : 48 %  SGPT : 15 U/L
 PLT : 217 x103/mm3  Ureum : 26 mg/dl
 PT : 10.4 second  Creatinine : 0.67 mg/dl
 INR : 0.96
 APTT : 28.3 second
 HbsAg : Non Reactive
 DIAGNOSIS

• Closed fracture 1/3 middle left ulna + Closed fracture

1/3 proximal left radius
MANAGEMENT

• ORIF elastic nail left radius ulna

Rehabilitation

• Early mobilization