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MUHAMMAD IKMAL HAZLI

TRISAKTI UNIVERSITY

BEKASI GENERAL HOSPITAL

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Name Mr D

Gender male

Age 28 years old

Address Bekasi

Occupation -

Religion Islam

First visit 14th

jan 2013

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Unable to move the left leg

On the left leg

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What? Unable to move

Where? Left leg

When? 3 months ago

How? (See next slide)

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28th sept 2012

1.00 am, going back from work

Accident. motorcycle vs motorcycle

Fell down left leg was hit by motorcycle

- passed out (unconscious)

- local people helped

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Transportation? Car , local residents

First aid? klinik patah

tulangMassage therapy?

left leg bandaged

Why see the doctor? Patients left leg is in a

state on immobility

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Similar condition (-)

Diabetes (-)

Hypertension (-)

Cholesterol (-)

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A. Vital Signs and Antropometry

BP : -

HR : 100 x/min equal

RR : 20 x/min

T : 36,5 oC

Consciousness: Compos Mentis,

GCS E4M6V5 = 15

Weight : 75 kg

Height : 170 cm

BMI : 25.9

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Head

Neck

Thorax

Abdomen

Ekstremities

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No swelling

No rednesslook

No painfeel

(next slide)move

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HIP Flexion 0-125 deg

Extension 0-30 deg

Adduction 0-25 deg

Abduction 0-45 degExternal rotation 0-60 deg

Internal rotation 0-40deg

Knee flexion0-140 degextension

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Swelling

Edema

The leg is bound in elastic bandagelook

Slightly warmer than other legfeel

(Next slide)move

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HIP Flexion

Extension

Adduction

AbductionExternal rotation

Internal rotation

Knee flexionextension

Tests not done

due to pain

from the

patient

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-Non union Fracture

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Non union Fracture in Left proximal Femoral

Shaft

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Operation

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The best teacher is

EXPERIENCE