UNIVERSITATEA DE STAT DE MEDICINA SI FARMACIA"NICOLAE TESTEMITANU"DIN REPUBLICA MOLDOVA

Department of Traumatology

MEDICAL REPORT

Represented to : Dr. O.Sergio

Represented by : Maher Harb \ Qassem Abu Khalil \ Husein Shahwan .

Group : 1439

15.11.2013General Data :

-First name : Andri-Last name : Sucan -Age : 28-Sex : Female-Social status : Single-Birth place : Anena Noi Zolotivka . -No history of hereditary family diseases.-The patient doesn't suffer from any type of allergies.-Harmful habits : No smoking / No alcohol.-Date of hospitalization: 31.10.13 , in hospital of traumatology in Chisinau

Diagnosis :Fracture of knee joint (the head of the tibia bone) of the right leg

History of present disease:

-This first time he come to the hospital -the patient need a surgical treatment < he came to the hospital to make surgery to solve this problem .

The past patient's history :

-Normal physical and mental development at birth-No history of TBC, HIV, Hepatitis infections in the past.-No hospitalization during his life.

Objective examination :

-General state : Good.-Consciousness : Clear.-Posture : Active.- Constitution : Normosthenic.- Normal facial expressions.-No local enlargement of the nick.-Normal elasticity and humidity -Normal hair growth.-Overweight patient.-Normal dimension , and no pain during lymph nodes palpation.-present of extremities abnormalities. -Pulse : 76 beats/min-Blood pressure : 124/79-Capillaries : 1 sec.

Respiratory System Examination :

- No complains.

- Inspections :1. Symmetrical right and lift sides.2. Clavicles and the shoulder blades are at the same level.3 Supraclavicular fossa equal on the both sides.

- Palpation :1. Normal thorax elasticity.2. Normal chest size and shape.3. Warm , dry skin.4. No tender spots.5. Symmetrical chest expansion.

- Percussion :1. Dullness indicates consolidation.2. Resonance Sound.3. Normal vibration.

-Auscultation :1. Normal vesicular breathing all over the lungs area.2. Normal trachea-bronchial breathing.3. No pathological signs.

Cardiovascular system examination :

- No complains.

- Inspection of the heart region :No pathological phenomenon ( swollen arteries , pronounced pulsation ..).

-Palpation:1. Apex beat present in the fifth intercostal space , with the area of 1.5-2 cm and a moderate height and power.2. No enlargement of the right ventricle.3. RV impulse , Epigastric pulsation , Jugular pulsation and thrills are absent.

- No pathological signs.

-Percussion :1. Normal size , position and shape of the heart.2. Normal length of the vascular bundle.3. Normal heart borders and configuration.

-Auscultation : No pathological signs during auscultation - no murmurs.

Digestive system examination :

- No complains.

- Inspection :1. Normal symmetric form and volume of the abdomen.2. Normal color of the abdomen.3. No signs of caput medusa was observed.4. No presence of surgical scars or other skin abnormalities.

-Auscultation :No pathological signs during auscultation.

-Palpation :No pathological signs appear during superficial and deep palpation of the abdomen.

Liver examination :

Inspection :no evidence of pulsation in the right hypochondrial space , no evidence of prominent vessels , no enlargement of the liver .

Palpation : No pain during palpation (no hardening and consolidation).Percussion :

No enlargement of the liver borders .

Gall-bladder examination :NoPalpation :No pain during palpation ( no hardening and consolidation )

Percussion :No pain during percussion.

Pancreas examination :

signs of enlarged pancreas wasn't detected.

Urinary system examination

- No complains related to the urinary system.

-Inspection : ( Lumbar region )1. No swelling regions was observed.2. Normal skin color.

-Palpation : ( Kidney palpation )The Inferior pole of the right and left kidneys was palpated.

Endocrine system examination:

-No complains.

-Inspection :1. No swelling regions was observed.2. Normal skin color .3. No signs of edema was observed.

-Palpation :Thyroid glands : no enlargement , no hardening , not mobile , no sensitivity in the area of the thyroid glands.

-Auscultation :No pathological signs during auscultation ( no bruits , no low pith humps - that may indicate goiter).

Traumatology status

- Complains :

1.Severe pain in the left leg (knee joint) during walking .2. irritated skin around the bunion.3. joint redness and pain3. the patient can not walk without help , she use one crutches always

-inspection :swelling of left leg and joint deformity of the right acetabulumno bruises no crackle during palpitation

-Vascular Status :1. Posterior tibial artery : normal2. Dorsalis pedis artery : normal

normal vascular status of the lower limbs .

-Neurological status :Normal sensory and motor function , no signs of neurological pathologies.

Treatment :

Recommended surgery , using of Blaca.T .Like this :

Indication at home :

-To use Crutches (2 crutches) during any movement (walking, exercise) Period of healing :

2-3 month's. after that control to the orthopedic doctor .

X-Ray :Fracture in the head of the tiboia in right leg .