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7/30/2019 Status Pasien OT 4
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Endy Jutamulia
030.08.094
University of Trisakti
Bekasi City General Hospital
Orthopedic
In-Patient status
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I. Profile
2
Name : Ch. R Gender : Male
Age : 10 y.o
Address : Jl. Kedondong 7 No.00RT/RW 00 Kranji, BekasiBarat
Occupation : Student
Religion : Muslim Race : Javanese
First visit : Thrusday, 4 Oktober 2012
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II. Chief Complaint
3
Left shoulder pain
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III. Medical history (October 4th 2012)
4
Left shoulder pain History of trauma: fell and hit the stair and injured the
shoulder
Sideswipe injury on Left shoulder
Hot packs as first aid on the spotSent with familys car to ER; e. verband
Shoulder X-ray were taken
Seizure (-), fainted (-), Nosebleed (-), Ear bleeding (-)
Swelling (+), Bruise (+), Blood (-), Fever (-), Patientoften does sport (volleyball)
History of DM (-),HT (-), Operation (-), Family (-),
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IV. Physical examination
A. Vital Signs
5
Blood Pressure : 120/80 mmHg
Heart Rate : 80 x/m
Respiration Rate : 24 x/m
Temperature : 36,5o
C General Condition : Tampak sakit ringan
Consciousness : Compos mentis,
GCS E4M6V5 = 15
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B. General Status
6
Head
Neck
Thorax
Abdomen
Ekstremities
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C. Status Lokalis
Left Shoulder
7
Look :
Dressed with Figure of 8Bandage
Bruise (-)
Redness (-)
Swelling (+)Open wound(-)
Feel:
Deformity (+)
Tenderness(+)
Warm (+)
Move:
Limited, painful ROM on flexionand adduction
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V. Supporting examination
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Xray3 Oktober 2012
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VI. Diagnosis
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Closed 2/4 middle of Left Clavicule fracture
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VII. Plan of Therapy
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Complete lab examination
Pre-operative preparation
Pro operation: ORIF Left Clavicule
(October 8th, 2012)
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Thank You
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Operation report
Pre-operative: Patient had taken a complete lab examination and
was consulted to pulmonologist and cardiologist
The lab results were normal without contraindicating
value Patient was declared fit for operation by
pulmonologist and cardiologist
Patient was given informed consent and planned tobe operated on Monday, October 8th 2012, 08.00
09.00
Patient was admitted to Tulip Room for pre-operativepreparation
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During operation: Patient was operated on Monday, Oktober 8th 2012, 08.00-
09.00 by Dr. dr. Fx Hendroyono, Sp.OT MARS
The diagnosis is closed complete fracture of left clavicule,and the planned operation is ORIF with clavicule plate &screw:
Patient lied in supine positionAseptic & antiseptic were done
Identification of fracture site
Incision of site in S Shape
Identification of fractured bone
Isolation of fractured bone from surrounding tissues
Reposition of fractured bone with reduction clamps
Fixation of bone with clavicule plate and screw
Site of operation is sutured layer by layer
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Patient was admittedto Tulip Room for
post-operative
observation
Xray for post-
operative
assessment was
taken on 17:20
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1st day Post op (9/ X/ 2012)
Left Clavicule Fracture, Post Operation. Pen is positioned well and steady
No Complicaiton is present from radiologic and laboratoric finding
Patient was allowed to go home
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Thank You