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NON-TRAUMATIC

CASE

ORTOPEDIC SURGERY
• Name : Mrs. R
• Age : 53 Years old
• Sex : Female

IDENTITY • Profession : housewife


• Address : Puwatu
• Admission : March, 28th 2017
• Doctor in charge : dr. Benny Murtaza, Sp.OT
• Chief Complaint : Pain at left thigh
• Anamnesis :
Suffered since 3 days ago. Pain is continuosly and being
severe day by day. Initially there was a wound on the upper
left thigh area and then spread to the lower area. The other
HISTORY complain such as fever (+) and sweeling.
• There was history of the same disease on December,
TAKING 2017.
• There was history of hip operation after traffic accident
on September, 2017.
• There was history of other disease : Hypercholestrol and
DM type 2 since a year ago.
• There was history of medicine treatment from cardiolog
and internist: using insulin everyday.
• There wasn’t know history of family disease.
Composmentis, moderate ill

Blood Presure = 130/80 mmHg


PHYSICAL
EXAMINATION Pulse = 76x/m, reguler, strong

Respiratory Rate = 20x/m, spontaneous,


simetris

Temperature = 37 OC (axillary)
Ears : within normal limit
Head : within normal limit
GENERALIZED Face : within normal limit
Neck : within normal limit

STATUS
Chest : within normal limit
Eyes : within normal limit
Extremity
Nose : within normal limit
Superior : within normal limit
Mouth : within normal limit
Inferior : Localized status
Coxae region

Inspection
Deformity (-), swelling (+), wound (+) diameter 0,5 cm, pus (+)

LOCALIZE
Palpation
Tenderness (+), felt warm (+)

STATE ROM
Active and passive movement of hip joint and knee joint are
limited due to pain
NVD
Sensibility is good, Pulsation dorsalis pedis artery (+), CRT ≤
2 seconds,
CLINICAL FINDINGS
Complete Blood
Count

PLAN OF
Chemistry blood
DIAGNOSTIC

X-Ray Femur Sinistra


AP/lateral
LABORATORY FINDING
COMPLETE BLOOD TEST BLOOD CHEMISTRY TEST
March 28th 2017 March 28th 2017
PARAMETER RESULT PARAMETER RESULT
WBC 10.035 /Ul Blood Glucose 177 mg/dl
Ureum 34 mg/dl
RBC 3.850.000 /uL
Creatinine 0,5 mg/dl
HB 10.3 g/dL SGOT 21 U/L
SGPT 17 U/L
PLT 283.000 x /uL
DIAGNOSE

Abses Left Coxae Region +


DM Type 2
DD : Osteomyelitis left femur
• PHARMACOLOGY
IVFD
Antibiotic injection
Analgetic injection

MANAGEMENT
H2RA injection

• NON-PHARMACOLOGY
Wound Care
Education

• CONSULT ORTHOPEDIC SURGEON


THANK YOU