UNIVERSITATEA DE STAT DE MEDICINA SI FARMACIA

"NICOLAE TESTEMITANU"
DIN REPUBLICA MOLDOVA

Department of Traumatology

MEDICAL REPORT

Represented to : Dr. O.Sergio

Represented by : Maher Harb \ Qassem Abu Khalil \ Husein

Shahwan .
Group : 1439

15.11.2013
General Data :
-First name : Andri
-Last name : Sucan
-Age : 28
-Sex : Female
-Social status : Single
-Birth place : Anena Noi Zolotivka .
-No history of hereditary family diseases.
-The patient doesn't suffer from any type of allergies.
-Harmful habits : No smoking / No alcohol.
-Date of hospitalization: 31.10.13 , in hospital of traumatology
in Chisinau

Diagnosis :
Fracture of knee joint (the head of the tibia bone) of the right leg

History of present disease:

-This first time he come to the hospital
-the patient need a surgical treatment < he came to the hospital
to make surgery to solve this problem .

The past patient's history :

-Normal physical and mental development at birth
-No history of TBC, HIV, Hepatitis infections in the past.
-No hospitalization during his life.

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.
-Overweight patient.
-Normal dimension , and no pain during lymph nodes palpation.
-present of extremities abnormalities.
-Pulse : 76 beats/min
-Blood pressure : 124/79
-Capillaries : 1 sec.
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.
3. No pathological signs.

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 :
No
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 left leg (knee joint) during walking .
2. irritated skin around the bunion.
3. joint redness and pain
3. the patient can not walk without help , she use
one crutches always

-inspection :
swelling of left leg and joint deformity of the right acetabulum
no bruises no crackle during palpitation
-Vascular Status :
1. Posterior tibial artery : normal
2. Dorsalis pedis artery : normal
normal vascular status of the lower limbs .
-Neurological status :
Normal sensory and motor function , no signs of neurological
pathologies.

Treatment :
Recommended surgery , using of Blaca.T .
Like this :

Indication at home :
-To use Crutches (2 crutches) during any movement (walking,
exercise)
Period of healing :
2-3 month's. after that control to the orthopedic doctor .
X-Ray :
Fracture in the head of the tiboia in right leg .