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    22-02-2019 Child. S, 6 Yo, Vulnus Laceratum Right Femur, Dr. Rizal Alisi, Sp. OT

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    eldacitrasari1994
    1) Child S, age 6, was admitted to the hospital on February 22nd 2019 after falling from a flagpole and sustaining injuries to his right thigh. 2) On examination, he had localized swelling, hematoma, and multiple lacerations measuring 12.5 cm x 2.5 cm and 3 cm x 0.5 cm on his right thigh. He also had tenderness and limited movement of his right hip and knee due to pain. 3) Diagnostic tests showed elevated white blood cell count. The diagnosis was a lacerated wound to the right femur. The treatment plan included IV fluids, analgesics, antibiotics, rest, wound care, and consultation

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    22-02-2019 Child. S, 6 Yo, Vulnus Laceratum Right Femur, Dr. Rizal Alisi, Sp. OT

    Uploaded by

    eldacitrasari1994
    47 views12 pages
    1) Child S, age 6, was admitted to the hospital on February 22nd 2019 after falling from a flagpole and sustaining injuries to his right thigh. 2) On examination, he had localized swelling, hematoma, and multiple lacerations measuring 12.5 cm x 2.5 cm and 3 cm x 0.5 cm on his right thigh. He also had tenderness and limited movement of his right hip and knee due to pain. 3) Diagnostic tests showed elevated white blood cell count. The diagnosis was a lacerated wound to the right femur. The treatment plan included IV fluids, analgesics, antibiotics, rest, wound care, and consultation

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    1) Child S, age 6, was admitted to the hospital on February 22nd 2019 after falling from a flagpole and sustaining injuries to his right thigh. 2) On examination, he had localized swelling, hematoma, and multiple lacerations measuring 12.5 cm x 2.5 cm and 3 cm x 0.5 cm on his right thigh. He also had tenderness and limited movement of his right hip and knee due to pain. 3) Diagnostic tests showed elevated white blood cell count. The diagnosis was a lacerated wound to the right femur. The treatment plan included IV fluids, analgesics, antibiotics, rest, wound care, and consultation

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    47 views12 pages

    22-02-2019 Child. S, 6 Yo, Vulnus Laceratum Right Femur, Dr. Rizal Alisi, Sp. OT

    Uploaded by

    eldacitrasari1994
    1) Child S, age 6, was admitted to the hospital on February 22nd 2019 after falling from a flagpole and sustaining injuries to his right thigh. 2) On examination, he had localized swelling, hematoma, and multiple lacerations measuring 12.5 cm x 2.5 cm and 3 cm x 0.5 cm on his right thigh. He also had tenderness and limited movement of his right hip and knee due to pain. 3) Diagnostic tests showed elevated white blood cell count. The diagnosis was a lacerated wound to the right femur. The treatment plan included IV fluids, analgesics, antibiotics, rest, wound care, and consultation

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 12

    IDENTITY

    Name : Child S
    Age : 6 years old
    Sex : Male
    Address : Mandonga
    Occupation : Student
    Admission : February, 22th 2019
    Doctor in Charge: dr.Rizal Alisi, Sp. OT
    A Clear, cervical spine control

    Respiratory rate 28x/m,


    B spontaneous, thoracoabdominal
    type, symmetrical, regular
    PRIMARY
    SURVEY
    (10.00 AM)
    C Blood Pressure 100/70 mmHg
    Pulse 100x/m, reguler, strong

    Glasgow Coma Scale (E4M6V5),


    D isochoric pupil, Ø 2,5 mm/2,5 mm,
    Light reflex +/+

    E Temperature 36,8ºC/Axillary
    SECONDARY SURVEY ( 10.05 pm)

    Anamnesis
    • Chief complain : Pain at right thigh
    • History Taking
    Suffered since ±20 minutes ago due to an accident
    • Mechanism of Trauma
    Patient was climb the flagpole, suddenly he fell down and the
    flagpole get his right thigh.
    • History of Trauma
    • There were no history of syncope, nausea and vomitting
    • There was no previous treatment
    GENERAL STATE Composmentis, moderate illnes, good nourish

    Vital Sign
    BP : 100/70 mmHg
    HR : 100x/minute, regular, strong
    RR : 28x/minute, regular, symmetrical
    T : 36,8◦C/axillary
    VAS : 4/10
    PRESENT STATE

    Head : Within normal limit Ears : Within normal limit


    Neck : Within normal limit
    Face : Within normal limit Chest : Within normal limit
    Eyes : Within normal limit Abdomen : Within normal limit
    Nose : Within normal limit  Upper Limb: Within normal limit
    Lower Limb: Localized State
    Mouth : Within normal limit Genitalia : Within normal limit
    LOCALIZED STATE
    • Right thigh Region

    I : Deformity (-), swelling (+), hematoma (+), wound (+) multiple vulnus
    laceratum with size 12,5 cm x 2,5 cm and 3 cm x 0,5 cm.

    P : Tenderness (+)

    ROM : Active and passive movement at right hip andright knee joint limited due to
    pain

    NVD : good sensibility, pultation right popliteal artery is palpable, CRT <2 Seconds
    Clinical
    Finding
    Routine Blood

    Planning Diagnostic :
    LABORATORIUM FINDING
    (22/02/2019)

    Routine Blood
    Parameter Result Unit Reference value
    WBC 14,56 10^3/uL 4.00-10.00
    HGB 11, 0 g/dL 12-16
    PLT 344 10^3/uL 150-400
    DIAGNOSIS
    Vulnus Laceratum Right Femur
    MANAGEMENT
    PHARMACOLOGY NON PHARMACOLOGY

    • IVFD • Rest
    • Analgetic • Education
    • Antibiotic • Wound Care
    Consult Orthopaedic Surgeon

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