Identity :

Name

: Ny.Marsiyem

Sex

: Female

Age

: 42 years old

MR

: 1707306112

Address

: Panjatan

Phone

: 081804095677

TB/BB

: 160 cm/62 kg

Occupation : Housewive
History :
Chief complaint

: pain on her right hip

History of present illness:

Since 1 year before admitted to the hospital, the patient felt pain in her right
hip. The pain was progressively getting worse. Then she went to an internal
medicine specialist in RSUD Wates, took medication, but the pain persisted.
1 month before admitted to the hospital. The pain persisted, she had walking
difficulty, and had to use a crutch to walk, she also felt her right leg shorter than her
left leg. Then she went to an internal medicine specialist, the doctor then referred
her to a neurologist, she had a radiology examination on her hip and being said that
there was a disorder on her right hip, then the doctor referred her to orthopaedic
outpatient clinic at Sardjito hospital.
History of past illness:
History of past trauma (+), at 1996, she fell down when step down from bus with
her right hip hit the ground first, but she didnt take any radiology examination.
History of SLE since 2008, routine examination in internal medicine specialist in
RSUD Wates,
took routine medication with methylprednisolon 5 mg 3 times a day as initial
medication, now she still take the methylprednisolon with dose 1 mg 3 times a day.
The patient occasionally complaining to her doctor about pain in her right hip, but
doctor said that it was related with the SLE and did not need any additional
medication or examination.

History of fever with right hip pain (-), history of chronic chough (-), night sweating
(-)
History of weight loss (-)
History of birth defect (-), patient had a normal growth and development.
History of DM (-), allergy (-), , dyspnea (-)
History of family illness:
History of same illness (-)
History of tumor (-)
Physical Examination :
a
b
c
d
e

Righ
t
Left

General Condition: Good, Compos Mentis

VS: Blood Pressure 130/80 mmHg, Heart rate: 92 bpm, Respiration
rate: 18, body temperature: afebrile
Head: Anemic of the Conjungtiva -/-, Icteric of the Sclera -/Neck: Lymphonodic enlargement (-)
Thorax:
i Lung: I: Symmetrical, Movement equal, Bruising (-)
P: Vocal fremitus D=L
P: Sonor +/+
A: Vesicular +/+
ii Heart: Cardiomegaly (-), Normal Heart Sound, Murmur (-)
Abdominal: I: Flat, Darm contour (-), Darm steifung (-), Bruising (-)
A: Bowel sound (+) normal
P: Tympanic
P: Soft, Tenderness (-), Defance muscular (-)
Local Status of the right hip joint:
Look : Deformity (+), swelling (-), shortening (+) 2 cm
Feel : Tenderness (+), Neuro Vascular Disturbance(-)
Move : Active extension flexion 0-60 limited due to pain
Passive extension flexion 0-70 limited due to pain

Apparent
Length
88 cm

True Length

90 cm

81 cm

79 cm

Assessment : Avascular Necrosis of The Right Femoral Head FICAT IV