CASE REPORTSaturday , January 17th 2015Team On Duty:dr. Hendra
K(Chief) dr. Rynaldi(Coordinator) dr. Tomi(Report editor) dr. Aswad
(Medical report) dr. Mohan(Medical report) dr. Andri
Feisal(documentation) dr. Rahmad(documentation)
I. Patient Identity Name : Yossi Perdana Putra Age : 10 years
old Sex : Male Address : Ujong Kalak, Johan Pahlawan, Kab. Sigli
MR: 1 03 68 41 Fathers Phone: 082368193863 Body Weight: 21 kg Time
Arrived: 11.44 PM
II. Chief Complain: Pain and difficulty moving of the left leg
III. Present illness history The patient was referred from Sigli
district hospital to Zainoel Abidin emergency room with a chief
complain pain and difficulty moving of the left leg for 2 days.
Initialy, he was playing with his friends and suddenly his friend
kicked him and he fell. There was no history of unconsciousness,
nausea and vomiting. IV. Physical examination Primary Survey A :
Clear B: Spontaneous, 22 breaths/min C: Blood Pressure: 120/70
mmHg, Pulse: 80 beats/min D: GCS 15, E4M6V5, isochoric pupil
3mm/3mm, light reflex (+/+) Exposure L/S at the left hip region L :
Symmetrical, hematoma (-), slight flexion, internal rotation,
adduction F : Pain (+), NVD (-) M : ROM limited at hip
Secondary survey Head and neck In normal limit Thorax In normal
limit Abdominal In normal limit Pelvic region L/S at the left hip
region L : Symmetrical,hematoma (-), slight flexion, internal
rotation, adduction F: Pain (+), NVD (-) M: ROM limited at hip
Upper extremity in normal limit Right lower extremity in normal
limit
V. Assessment: Posterior dislocation of the left hip
VI. Management Immobilization IVFD RL 10 drips/mnt Ketorolac
injection 10 mg Laboratory examination Radiology examination
VII. Laboratory result Haemoglobin : 12,0 gr/dl White Blood
Count : 16,700 /ul Platelets : 319.000 /ul Hematocrit : 35 % CT/BT:
7/2 Radiology result : Pelvic APPosterior dislocation of the left
hip
VIII. Diagnose Posterior dislocation of the left hip jointIX.
Consult to orthopedic surgery division Close reduction
emergency
X. Operative report Performed close reduction with Bigelows
Manuver The left hip joint dislocation was release Performed skin
traction XI. Post Operative DiagnosedPosterior dislocation of the
left hip joint (ICD 10 CM S73.012)
XII. Follow upDate S O A P
19/1/2015POD 1 Pain (-) General Condition: Good BP : 100/70 mmhg
P : 86 beats/minute RR : 20 breath/minute T : 37 CL/S at the pelvic
region L: symetricalF: Pain (-)
L/S at the left FemurL : Skin traction (+)F: Pain (-)M: Limited
Posterior dislocation of the left hip joint (ICD 10 CM S73.012)
Post close reduction(ICD 9 CM 79.75) IVFD RL 10 drips/mnt Inj
Metamizole Sodium 500 mg/8 hours
Performed skin traction
