Bed

Site
Teaching
Jasika Lukita Pertiwi
(712015001)

Preceptor:
dr. Rizal Daulay, Sp.OT.,MARS.
 Identification
Name : M. Awfa Alfazar
Age : 2 years old
Gender : a boy
Religion : Moslem
Occupation : (-)
Address : belitang, Ogan
Komering Ulu
 Chief Complain

Cant stand up and

unable to walk
 Clinical History
About 6 month ago he cant stand up and
unable to walk. before he fell while a playing
bicycle. He mom said before he can stand up
and walk a slowly, He have weight loss an
then lower left legs look a like different and he
skin many freckles since childhood. He go to
the hospital in belitang and check a rotgen he
legs. And then he go to the alternative
treatment for to get massage his limbs and
then he parents decide go to hospital
Muhammadiyah Palembang.
General State
- General Condition : Well
- Sens : Compos Mentis
- Vital Sign
Pulse Rate : 105
x/minute
Respiratory Rate : 22
x/minute
Temperature : 36,6 C
 Local State
Left lower Legs
Region
Look :
surgical scar (-), wound (-),
bleeding (-), skin loss (-),

bone expose (-),

deformity (+),
swollen (-),discolouration (-),
Hiperpigmentasi (+)
 Local State

Left lower legs sinistra

Feel :
tenderness (-), crepitation (-),
temperature same like the right
one,
NVD (+), muscle atrophy (-)
 Local State
Left lower legs sinistra

Move:
limited movement
Clinical Photo
Clinical Photo
 3 march
X-Ray 2016
X-Ray 20 september 2016
 Assessment
The fracture phatologic tibia and fibula
sinistra and Neurofibromatosis.
 Planning

Surgical
- Open Reduction and
Internal Fixation (ORIF)
GOMAWO