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Department of Traumatology

MEDICAL REPORT





Represented to : Dr. Vitalie Chirila

Represented by : Fadi Arram

Group : 1450





26.05.2014
General Data :

-First name : Rotari
-Last name : Seafim
-Age : 56 (12/10/1957)
-Sex : Male
-Social status : Married
-Birth place : Chisinau
-Work at: SRL-Ford Company Security
-Harmful habits : smoke[YES] / alcohol[Yes].
-Date of hospitalization: 02.05.13 , in hospital of traumatology in
Chisinau at 12:40 PM

Diagnosis :
Femoral neck fracture in the right leg
GARDEN IV:- complete fracture, completely displaced
AO CLASSIFICATION:-
31-B3
extraarticular fracture, neck, subcapital, displaced, nonimpacted


History of present disease:
In 1.5.2014 at night the patient fall down at home at his right femoral
neck region and he felt Sudden onset of sharp; bruising and pain on
firmly touching the affected region of bone. Pain increase during trying
movements of his leg and during standing or walking.
He went immediately 1.5.2014 at night after falling down to one hospital
in Raion Village and his 1
st
aid was IV Analgetic and Antibiotics, after
that he went home in the same night and the next day in 2.5.2014 at
12:40PM he came to the traumatology hospital in Chisinau (More than 12
hours left).

Investigations:
-X-ray
-Blood analysis
-Urine analaysis

The past patient's history :

-Neurological status encephalopathy
-No history of TBC, HIV, Hepatitis infections in the past.

Objective examination
-General:state : Good.
-Consciousness : Clear.
-Posture : Active.
-Constitution : Normosthenic.
-Normal facial expressions.
-No local enlargement of the nick.
-Normal elasticity and humidity
-Normal hair growth.
-normal weight patient.
-Normal dimension , and no pain during lymph nodes palpation.

Respiratory System Examination :

- No complains.

- Inspections :
1. Symmetrical right and lift sides.
2. Clavicles and the shoulder blades are at the same level.
3 Supraclavicular fossa equal on the both sides.

- Palpation :
1. Normal thorax elasticity.
2. Normal chest size and shape.
3. Warm , dry skin.
4. No tender spots.
5. Symmetrical chest expansion.

- Percussion :
1. Dullness indicates consolidation.
2. Resonance Sound.
3. Normal vibration.


-Auscultation :
1. Normal vesicular breathing all over the lungs area.
2. Normal trachea-bronchial breathing.


Cardiovascular system examination :

- No complains.

- Inspection of the heart region :
No pathological phenomenon ( swollen arteries , pronounced pulsation
..).

-Palpation:
1. Apex beat present in the fifth intercostal space , with the area of 1.5-2
cm and a moderate height and power.
2. No enlargement of the right ventricle.
3. RV impulse , Epigastric pulsation , Jugular pulsation and thrills are
absent.

- No pathological signs.

-Percussion :
1. Normal size , position and shape of the heart.
2. Normal length of the vascular bundle.
3. Normal heart borders and configuration.

-Auscultation :
No pathological signs during auscultation - no murmurs.


Digestive system examination :

- No complains.

- Inspection :
1. Normal symmetric form and volume of the abdomen.
2. Normal color of the abdomen.
3. No signs of caput medusa was observed.
4. No presence of surgical scars or other skin abnormalities.

-Auscultation :
No pathological signs during auscultation.

-Palpation :
No pathological signs appear during superficial and deep palpation of the
abdomen.


Liver examination :

Inspection :
no evidence of pulsation in the right hypochondrial space , no evidence of
prominent vessels , no enlargement of the liver .

Palpation :
No pain during palpation (no hardening and consolidation).
Percussion :

No enlargement of the liver borders .


Gall-bladder examination :

Palpation :
No pain during palpation ( no hardening and consolidation )

Percussion :
No pain during percussion.


Pancreas examination :

signs of enlarged pancreas wasn't detected.
Urinary system examination :

- No complains related to the urinary system.

-Inspection : ( Lumbar region )
1. No swelling regions was observed.
2. Normal skin color.

-Palpation : ( Kidney palpation )
The Inferior pole of the right and left kidneys was palpated.


Endocrine system examination:

-No complains.

-Inspection :
1. No swelling regions was observed.
2. Normal skin color .
3. No signs of edema was observed.

-Palpation :
Thyroid glands : no enlargement , no hardening , not mobile , no
sensitivity in the area of the thyroid glands.

-Auscultation :
No pathological signs during auscultation ( no bruits , no low pith humps
- that may indicate goiter).








Traumatology status


- Complains :

1. Severe pain in the right femoral hip region.
2. bruising and pain on firmly touching the affected region of bone.
3. the patient can not walk or stand on his affected leg.

-inspection :
swelling of the upper part of right leg
deformity is noticeable:-
-abduction
-shortening
-external rotation
-he cant rise his leg
crepitus
discontinuity

-Vascular Status :
Bad blood supply

-Neurological status :
Normal sensory and motor function , no signs of neurological
pathologies.

-Radiological describe:-
X-ray examination we can see fracture of the Femoral Nick with
dislocation.











Treatment :
Surgical Treatment:
Total Hip Prosthesis


Indications at Home:-
-Using Crutchs at least 3 months and without pressure.
-Physiokinetic Therapy after 2 weeks.
-Control after 3 months.

Conclusion:
After falling down he didnt go to the hospital immediately and the
fractured region was at the femoral neck region (very bad
vasculation) so the next day after what he come to
Traumatological hostpital the doctor decided to make a total
femoral prosthesis and I think its the best idea to avoid femoral
bone necrosis and also because he still young and active.