close fracture 1/3 middle left femur

Name : Mr.MG
Age : 33 years old
Address : Konawe
Admission :August, 1st 2017
Chief Complain : pain at left thigh

ANAMNESIS

A patient reffered from konawe hospital. He Came with complain was a pain at
the left thigh that he felt since about 11 hours ago..

MOT

The patient has got an operation for his fracture at the left femur since 2
months ago. When he tried to move from the bed to the floor, suddenly he
heard a strange sound and he felt pain at his left thigh.

HISTORY

unconsiousness(-)
vomiting (-)
Nausea (-)
He has an operation history before getting his first operation that caused by an
accident 2 months ago.
 Primary survey

A Clear

RR 20 x/min regular, spontaneous

thoracoabdominal type, symmetrical B
C BP 110/70 mmHg
Pulse = 60 x/min, regular, strong

GCS 15 (E4M6V5), pupil isochors,

: 2,5mm/2.5mm, light reflex +/+ D
E T = 36,50 C (axillary)
 SECONDARY SURVEY
Head : normally
Face : normally
Eyes : normally
Ear : Normally
Nose : normally
Mouth : normally
Neck : Normally
Thorax : Normally
Abdomen : Normally

GENERAL STATUS
 LOCAL STATUS
(left waist)
I :deformitas (+), hematom (-), Udem (+),
scar (+)
P :tenderness (+)
ROM :active and pasive movement at the left foot
was limited due to pain
NVD :sensoric and sensibility was normally, CRT
<2 second

SECONDARY SURVEY
CLINICAL FINDING
 Comminutive Complete
fracture at 1/3 medial region of
left femur.
Multiple fragment at medial
and came along with soft
tissue swelling.
There was screw at proximal
area with lateral fixation of left
femur.
 A patient reffered from konawe hospital. He Came with
complain was a pain at the left thigh that he felt since about 11
hours ago.
On physical examination there were deformitas, edema, and
scar. Active and passive movement are limited due to pain
On radilogic examination femur AP there was fraktur 1/3
middle left femur
 close fracture 1/3
middle left femur
 Non Spalk
farmakologi

Analgetic
Farmakologi
Antibiotic

Consult to orthopedic