Identity

• Name : Ch. M
• Age : 8 years old
• Sex : Male
• Address : Salomo Street
• Occupation : Student
• Admission : December, 30th 2018
Anamnesis (19.10 WITA)

• Main Complain : right thigh pain

• History Taking: suffered since 3 hours ago after fall down
 Mechanism of Trauma: the patient was ride a bicycle and suddenly fall from
his bicycle. The next mechanism was unknown
 There was no history of unconsciousness, nausea, and vomiting
 There was no history of drugs and alcohol consumption
 There was no history of previous treatment
Primary Survey (19.04 WITA)

A Clear, cervical spine control

B RR: 22 times/minute, symmetrical, thoracoabdominal type

C BP: 110/70 mmHg, Pulse: 96 times/minute, strong, regular

D GCS E4V5M6, isochoric pupil diameter 2.5 mm/2.5 mm, LR (+/+)

E Temp.: 36,5oC/axillar
Secondary Survey (19.17 WITA)

• General state:
Moderate illness, Composmentis, well nourished (BW: 35 kg)
• Vital Sign:
Blood Pressure: 110/70 mmHg
Pulse: 96 times/minute, regular, strong
Respiratory Rate: 22 times/minute, regular
Temperature: 36,5oC/axillar
VAS : 8/10
Present State
Head : Within normal limit
Eyes : Within normal limit
Ears : Within normal limit
Nose : Within normal limit
Mouth : Within normal limit
Neck : Within normal limit
Chest : Within normal limit
Abdomen : Within normal limit
Back : Within normal limit
Genitalia : Within normal limit
Superior Ext : Within normal limit
Inferior Ext : Localized
Localized State

Right Thigh Region

• Inspection: deformity (+), swelling (+), hematoma (-), excoriated

wound
• Palpation: tenderness (+)
• ROM: active and passive movement of right hip joint and knee joint
limited due to pain
• NVD: sensibility was good, Tibia posterior Artery pulsation was
palpable, CRT < 2 seconds
Clinical Pictures
Plan of Diagnostic

• Routine Blood Test

• X-Ray Right Thigh AP/Lateral
Laboratory Findings

Routine Blood
30/12/2018
Parameter result Unit Reference
value
WBC 18,66 103/uL 4.00-10.00

HGB 10,9 g/dL 12-16

PLT 433 103/uL 150-400

Radiology Findings
Diagnosis:
Closed Fracture 1/3 proximal of Right Thigh
Differential Diagnosis:
• Dislocation of right hip joint
• Muscle contusion of right thigh
Management

Non Pharmacological Pharmacological

• Rest
• IVFD
• Immobilization
• Ice Compress • Antibiotic Injection
• Elevation • Analgesic injection
• Education • H2RA Injection

Consult to orthopedic surgeon

THANK YOU 