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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

9

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