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Name : Mr. A
Age : 25 years old / Male
Address: South Konawe
Admission : November 11th, 2015
DPJP : dr. Tri Tuti H, Sp. OT
HISTORY TAKING
Chief Complain : pain at left leg
Anamnesis :
Chief Complain: Patient come to the hospital with pain at left leg
suffered since two hours before admitted to the hospital due to
traffic accident.
History:
Injury, inability,
fracture is not always General sign:
in the injury site, age Shock or bleeding,
and mechanism of brain and medulla
trauma, swelling, spinalis injury
deformity, hiposthesia
and unconscious
Local sign:
Look: deformity,
swelling, hematoma,
open wound and bone
expose
Feel: tenderness and
crepitation
Move: Active and
passive movement
Diagnose
Phisical
History Examinati
n
Additional
examinati
on
Management
Closed Open
reduction reduction
Prognosis