Uminah

Female/53 yo
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 IDENTITY
Name : Uminah

Age : 53 years old / Male

Registration : 992915

Status : JKN
ALLOANAMNESIS

Chief Complain : Pain at the right wrist joint

• Suffered since 2 month before admitted to Wahidin Sudirohusodo General
Hospital. At the beginning patient was walking in the terrace of the mosque, and
then she got slipped , and then she was fallen with her right hand holding the
floor, after the accident patient felt pain aand swelling on her right wrist joint,she
was bring her complain to the doctor in policlinic , but the doctor said there was
no problem, several days after she felt her complain is not getting better, she tried
go to bone setter , but her pain and swelling didn’t get better, and then in the next
two month she was got referral to Wahidin general hospital.
• The patient was just worked in house and right hand domminant.
• There was no history of Diabetes Melitus
• There was no history of hypertension
GENERAL STATUS

• Composmentis
• Vital Signs:
Blood pressure : 130/70 mmHg
Pulse rate : 86 beats per min
Respiratory rate : 20 times per min
Temperature : 36,2 0C
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 CLINICAL FINDING

Right wrist joint Region

Look : Deformity (+), Swelling (-), wound (-)

Feel : Tenderness (+)

Move : Active and passive movement of wrist joint cannot be evaluated due to
pain
NVD : Sensibility is good., capillary refill time less than 2 second, radial artery
and ulnar artery are palpable
 DIAGNOSIS
Malunion Fracture distal right radius
Right DRUJ injury
 MANAGEMENT
• ORIF Reconstruction distal right radius