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II. CHIEF COMPLAINT
Limping
[email protected] September 2014
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III. HISTORY TAKING
Limping since 5 months ago due tosingle motorcycle accident, velocity >
80km/hour. As he fell, his left leg got
caught under the vehicle. Patientunabled to move his left leg right after.
Wound (-), unconsciousness (-)
retrograde amnesia (-), nausea /vomiting (- / -), helmet (+).
[email protected] September 2014
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No first aid at the accident site.Patient has immediately taken to the
bone shelter by motorcycle, treated
with massaging and traditionalsplinting method for 1 week
(inpatient). He came for check up
every 1 week for 1 month.
30 September 2014 [email protected] 5
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Three months after the accident,the pain subsided but the left leg
seemed shorter than other and
caused limping.
30 September 2014 [email protected] 6
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IV.PHYSICAL EXAM
A. General data
Fully alert, mild illness
Vital sign:
BP :120/80 mmHg, HR:100 BPM,RR:18x/mins, normothermia
Gait:
Use crutch(Limping without crutch)
[email protected] September 2014
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B. Head to toe
Head :
Eye: Anemic (-) Jaundice (-)
Neck : Lymphadenopathy (-)
Thorax :
Pulmo : VBS right=left,Wheezing/rhonchi/rales(-)
Cor : heart sound reguler, murmur(-),
gallop(-)
Abdomen:
Flat, soft, bowel sound (+), tenderness(-), mass (-)
Extremity : see local data
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C. Local dataLeft leg region
Look :
Deformity
(-/+, LLD:2 cms)
Skin (intact/intact)
Discolorization
(-/redness on the medialaspect of lower leg)
[email protected] September 2014
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C. Local dataLeft leg region
Feel :
Warmth (-/+ on the medialaspect of lower leg)
Tenderness (-/+)Dorsalis pedis a. (regular,equal, normal pulsation)
CRT < 2
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C. Local dataLeft leg region
Move :
Knee
Flexion (135/ 135) (N: 135)Extension (0/ 0) (N: 0)AnklePlantar flexion (55/30) (N: 55)Dorsiflexion (15/10) (N: 15)
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V.SUPPORTING EXAMINATION
LABORATORY
Pre op Post op
- -
[email protected] September 2014
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30 September 2014 [email protected] 14
X-RAY
Knee not visualized
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VI.DIAGNOSIS
Malunion Fracture of the Left Tibia ICD X Code: S82.222P
Displaced transverse fracture of shaft of left
tibia, subsequent encounter for closed fracturewith malunion
Malunion Fracture of the Left Fibula
ICD X Code: S82.422P
Displaced transverse fracture of shaft of left
fibula, subsequent encounter for closed
fracture with malunion
[email protected] September 2014
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VII.TREATMENTS
A. Surgery Refracturation
ORIF
B. Physiotherapy
[email protected] September 2014
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30 September 2014 imel [email protected] 17