CASE REPORT

PHYSICAL MEDICINE &

REHABILITATION
NURUL SAFIAH HAMIZAH BINTI SUHAIMI,
C111 12 809
ELY ZAFIRAH
SHANIN

PATIENT IDENTITY
Name
: Mr. M
Sex
: Male
Date of Birth
: 12/12/1960
Religion
: Islam
Address
: Ponci, Bulukumba
Occupation : Government worker
Medical Record : 768178

Consultation
form
Orthopedic
Department
Inpatient Clinic (Lontara 2/ Kamar 8/ Bed 5)

HISTORY TAKING : ANAMNESIS

Chief Complaint : POST EXTERNAL FIXATION
Patient comes to the hospital after involves in an
accident with a motorcycle, before the accident happen
patient complains of pain at left leg. The pain did not
affect the daily living.
Patient involves with an
accident, and use his left as a support when the accident
happen. There is lacerated & stitched wound at left.
There is hematom and oedema. The patient also
complains of tenderness. There is no history of fainting,
nausea and vomitting.

PHYSICAL EXAMINATION

General condition : compos mentis

BMI

: 18.73 kg/m2, BB : 45 kg, TB : 1.55 m

Vital Signs :
BP

: 110/70 mmHg
HR
: 86x/minute
RR : 24x/minute
Temp : 36.7 0C

GCS : E4M6V5

Ambulation : VAST : 4/10

STATUS LOKALIS
Lower Extremities Region
Regio Genu Dextra

1) Inspection :
- Lacerated wound at anterior of proximal
tibia with the size of 4cmx0.5cmx0.5cm.
- Stitched wound at anterior aspect 1/3 distal
from medial to lateral with the size of 8cm
- Bone exposed at posterolateral distal of cruris
- Hematom (+), Oedema (+)
2) Palpation : Tenderness (+)

MUSCULOSKLETAL STATUS

ROM OF KNEE SINISTRA

Flexion

: - patient is wearing a cast

Extension : - patient is wearing a cast
Internal rotation : - patient is wearing a cast
External rotation : - patient is wearing a cast

NEUROLOGY STATUS

Sensoric test : The patient can feel the sensation

given, and the sensation is the same for both
dorsal surface of the foot

RADIOLOGIC EXAMINATION
Foto Cruris AP/Lateral
Allignment pembentuk cruris sinistra
berubah, tidak tampak dislokasi
Tampak fraktur kominutif 1/3 distal os
tibia sinistra dan fraktur transversal os
fibula sinistra dengan frgmen distal ke
arah cranioanterior, fragmen proximal
ke arah posterocaudal displace sejauh
3.1 cm serta shortening 2.6 cm
Mineralisasi tulang baik
Celah sendi yang tervisualisasi intak
Jaringan lunak sekitar kulit sulit
dievaluasi

Foto Ankle Joint Sinistra Mortise View

Allignment pembentuk ankle joint sinistra berubah, tidak tampak dislokasi
Tampak fraktur kominutif 1/3 distal os tibia sinistra dan fraktur transversal os fibula sinistra dengan frgmen
distal ke arah cranioanterior, fragmen proximal ke arah posterocaudal displace sejauh 3.1 cmserta shortening
2.6 cm
Mineralisasi tulang baik
Celah sendi yang tervisualisasi intak
Jaringan lunak sekitar kulit sulit dievaluasi

THERAPY

Medication
RL

20 tpm
Vialin 1500 mg/8hr/IV
Hypobach 300 mg/12hr/IV
Metronidazole 500 mg/8hr/IV
Ketorolac 1amp/8hr/IV

Surgery : OREF from Orthopedic Department

Physical Medicine and Rehabilition

Total

bed rest
Elevation of feet

DIAGNOSIS (ORTTHOPEDIC)
Open communitive fracture distal left tibia grade
III A
Open segemntal fracture distal left fibula grade
III A

DIAGNOSIS (RM)
Post external fixation EC
Impairment

: Post external fixation EC

Disability : Cast that prevent ambulation
Handicap : Unable to continue working