Mohd Shahir

8/17/2019 Mohd Shahir

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Orthopaedics

CASE WRITE UP

Name of student: Muhammad Shahir bin Mohd Idris

ID number : 1000!"0!#$at%h : &ear ' (rou) "

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NAME: *A+I,UDIN SU-AIMAN

A.E: !1 /EARS -D

SE: MA-E

ET*NIC .RUP: MA-A/

MARITIA- STATUS: MARRIED

CCUPATINA-: UNEMP-/ED

DATE + ADMISSIN: 2343!015

DATE + C-ER6IN. : 1!304315

IN+RMANT: PATIENT

CHIEF COMPLAINT

A77e(ed M8A and )ain o9er the ri(ht rist ;oint area )ast a%%ident

HISTORY OF PRESENTING COMPLAINT

Patient as )re9ious7& e77 unti7 4 da&s a(o hen he in9o79ed in an a%%ident at ni(ht

around 11m3h< *e unab7e to sto) his bi>e or turn aa& from that %rossed

motor%&%7e< Then at s)eed around 110>m3h he hit the side of the %rossed motor%&%7e= and

he as thron aa& from his bi>e= %ross the motor%&%7e that he hit= and fa77ed on the

road= dra((ed and ro77in( on the road around !0 meter

*e fe7t on the road ith fa%e and ri(ht hand first= in >nee and rist ;oint in e@tended

)osition< *oe9er due to the hi(h im)a%t= he unab7e to 7and ni%e7&= and his fa%e hit the

road= and there as a %ra%> sound heard b& him after he 7anded the hand<

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After sto) ro77in( on the road= he ab7e to stand for a hi7e= no )ain o9er both 7oer 7imb=

hoe9er he unab7e to mo9e his ri(ht forearm= and fin(er due to the se9ere )ain o9er that

area< *e a7so noti%ed o)en ound sai around 4%m@!%m ith fra(ment of the fra%ture

bone o9er the dorsa7 as)e%t of dista7 forearm around the rist ;oint< No a%ti9e b7eedin(

noted< +e se%ond after that he %o77a)sed= unsure hat has ha))ened to him unti7 he

o>e u) ne@t da& in hos)ita7<

n further Buestionin(= after he o>e u) in hos)ita7= no si(n of raised ICP noted< *e den&

an& )ro;e%ti7e 9omitin(= no b7urrin( 9ision= or heada%he= and no 7oss of re%ent or remote

memor&< There as a7so no si(n of .7as(o Coma s%a7e deterioratin( 7i>e no ea>ness

or )rob7em ith s)ee%h= no 7oss of e&e res)onse= or no mus%7e )rob7em or inabi7it& to

res)onse to motor fun%tion<

No fe9er su((esti9e of infe%tion at the side of ound< No features of thora%i% or %hest

in;ur&= no %hest )ain= no )ain durin( inha7e or e@ha7e= no shortness of breath= no

hemo)t&sis= and no hematemesis and me7ena or abd )ain su(eesti9e of intra abdomina7

b7eedin(<

There as a7so no si(n of 9ertebra73s)ina7 %ord in;ur&= no ne%> )ain= no 9ertebra7 )ain= he

as ab7e to mo9e a77 4 7imbs= urination and boe7 habits as norma7<

Due to the a%%ident= his front teeth as bro>en= 7a%eration ound o9er his 7i)s= )ain o9er

the nose= and mu7ti)7e abrasion ound on both 7oer 7imbs and u))er 7imbs< Due to the

hi(h im)a%t= he suffer a fra%ture o9er his ri(ht forearm<

Therefore= he under(one o)en redu%tion e@terna7 fi@ation and ound debridement 1 da&

after the a%%ident<

Current7& )atient is stab7e= not in )ain= and afebri7e<

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PAST MEDICAL / SRGICAL HISTORY

*e has no under7&in( %hroni% disease 7i>e *PT= DM= asthma= T$= or %on(enita7 heart

disease<

*e ne9er admitted to hos)ita7 or under(o an& sur(i%a7 )ro%edure before

DRG HISTORY ! ALLERGIES

Current7&= )atient on7& on ana7(esi%s (i9en b& the hos)ita7= no o9er en%ounter dru(s

ta>en< Patient has no >non a77er(& to an& medi%ation<

FAMILY HISTORY

*e is the #th out of 11th sib7in(s< A77 are e77 and hea7th&< +ather and mother sti77

hea7th& ithout an& medi%a7 i77nesses< *e %urrent7& ta>en %are b& mother durin( hos)ita7

admission< No histor& of bone %an%er or an& ma7i(nan%& in the fami7&<

SOCIAL ! EN"IRONMENTAL

*e is a non smo>er= non a7%oho7i%= and non dru(s abuser< *e 7i9es in a sin(7e store&

house ith (ood basi% amenities< *e is unmarried= %urrent7& unem)7o&ed= his fami7&

a%onom& is enou(h to su))ort the ho7e fami7&<

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PHYSICAL E#AMINATION

GENERAL E#AMINATION

.enera77& he is stab7e= %ons%ious= a7ert= e77 orientated to time )7a%e and )erson= not in

)ain= not in shortness of breath= nutritiona7 and h&drationa7 status seems norma7< There

are mu7ti)7e abrasion ound o9er the fa%e= %hest= hand and 7oer 7imb< There is a7so

sub%on;un%ti9a7 hemorrha(e<

9er the ri(ht hand= there is e@terna7 fi@ation inserted o9er the dorsa7 as)e%t of the

forearm %rossed the rist ;oint= 4 )ins and ! rods< ! )in atta%hed to the se%ond meta%ar)a7

bone and another ! )ins is atta%hed to the dista7 radia7 bone<

<

A77 his 9ita7 si(ns ere ithin norma7 ran(e as fo77o

• $7ood )ressure : 1153#0 mm*(

• Pu7se : 5!b)m= norma7 9o7ume= re(u7ar rh&thm

• Res)irator& rate: !0 breath )er minute

•

Tem)erature : "5


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FEEL

Tem)erature are norma7 on both side and a77 area< There is tenderness o9er the bon&

stru%ture both u7nar bone and radia7 bone at the dista7 )art< Ca)i77ar& refi77 time 7ess than

! se%onds< Sensation is inta%t= on a77 area= soft tou%h= )ain and ! )oint dis%rimination are

inta%t< The radia7 )u7se is )resen%e ith norma7 9o7ume<

MO"E

Shou7der ran(e of mo9ement are norma7= no )ain or tenderness< No restri%ted mo9ement<

E7bo ab7e to f7e@ and e@tend< *oe9er he unab7e to mo9e the rist due to the e@terna7

fi@ation< +in(er abdu%tion= addu%tion= f7e@ion and e@tention is norma7<

FOR OTHER SYSTEM E#AMINATION

CARDIO"ASCLAR SYSTEM

n ins)e%tion of the %hest= the %hest mo9e s&mmetri%a77& ith res)iration< There

as no %hest deformit&= no sur(i%a7 s%ar= no di7ated su)erfi%ia7 9ein= no 9isib7e )u7sation

and no s>in dis%o7ouration<

n )a7)ation= the a)e@ beat as 7o%ated at ' th inter%osta7s s)a%e ithin the 7eft

mid%7a9i%u7ar 7ine< No hea9e or thri77 noted<

n )er%ussion re9ea7ed norma7 %ardia% du77ness<

n aus%u7tation= norma7 first se%ond heart sound as heard< There as no

murmur<

A77 the )eri)hera7 )u7ses ere )a7)ab7e and the ;u(u7ar 9enous )ressure F8PG as

not raised

RESPIRATORY SYSTEM

n ins)e%tion of the %hest= the %hest mo9es s&mmetri%a77& ith res)iration= there

as no %hest deformit&= no use of res)irator& a%%essor& mus%7e= no sur(i%a7 s%ar= no

di7ated 9ein= and no inter%osta7s= sub%osta7s and su)rasterna7 re%ession<

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n )a7)ation= the tra%hea as %entra77& 7o%ated= norma7 %hest e@)ansion= and

norma7 9o%a7 fremitus at both u))er= midd7e and 7oer one< A)e@ beat as )a7)ab7e at

the 5th inter%osta7s s)a%e at the 7eft mid%7a9i%u7ar 7ine<

n )er%ussion= there as norma7 resonan%e anterior and )osterior7& and norma7

%ardia% and 7i9er du77ness ere noted

n aus%u7tation= 9esi%u7ar breath sound as heard ith norma7 air entr& and

norma7 9o%a7 resonan%e of both sides< No %re)itation and rhon%hi noted<

A%DOMINAL E#AMINATION

n ins)e%tion the abdomen as f7at< There as no ob9ious se77in(< The

abdomen mo9es norma77& ith res)iration< No 9isib7e )erista7sis= no su)erfi%ia7 di7ated

9ein= the umbi7i%us as %entra77& 7o%ated in9erted and the hernia7 orifi%es ere inta%t<

n )a7)ation= the abdomen as soft= non? tender= no mass )a7)ab7e< There as no

he)atos)7enome(a7&< The >idne&s ere not ba77otab7e<

n )er%ussion= there as no area of du77ness and ne(ati9e shiftin( du77ness<

n aus%u7tation= norma7 boe7 sound as heard<

CENTRAL NER"OS SYSTEM

Menta7 status Patient as a7ert= %ons%ious and oriented to time= )7a%e and )erson<

Crania7 ner9e A77 %rania7 ner9es ere inta%t<

Mus%7e tone There ere no mus%7e astin(= abnorma7 mo9ement and fas%i%u7ation

of her u))er and 7oer 7imb< Norma7 mus%7e tone of both u))er

and 7oer 7imbs<

Mus%7e )oer Norma7 mus%7e )oer of both u))er and 7oer 7imbs '3'G

Ref7e@es A77 tendon ref7e@es ere norma7

Ref7e@es -eft Ri(ht

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Fa Fer> HH HH

$i%e)s HH HH

6nee HH HH

An>7e HH HH

P7antar Don (oin( Don (oin(

Cerebe77ar Si(ns There as no %erebe77ar si(n )resent and his (ait as norma7

n sensor& e@amination= there as no im)aired sensation<

CLINICAL SMMARY

!1 &3o men a77e(ed m9a admitted due to )ain and 7oss of fun%tion at the dista7 ri(ht

forearm around the rist= under(one o)en redu%tion interna7 fi@ation one da& after

admission<

PRO"ISIONAL DIAGNOSIS

)en fra%ture of the dista7 "rd radius= (usti7o %7assifi%ation t&)e "A<

Point for : 1G he noti%ed o)en ound ith bone fra(ment after the a%%ident sie 4@1%m

!G tenderness o9er the dista7 radius of the ri(ht hand durin( PE

"G +a77 ith h&)er e@tended hand= rist and e7bo<

4G )en redu%tion e@terna7 fi@ation as done 1 da& after a%%ident= ! )in

abo9e the rist ;oint on !nd meta%ar)a7 boneG and ! )in on the dista7

radius

'G ab7e to f7e@ and e@tend a77 fin(ers e77= ru7e out %ar)a7 and meta%ar)a7 bone fra%ture

DIFFERENTIAL DIAGNOSIS

1G +ra%ture of dista7 u7nar of ri(ht hand

!G +ra%ture both dista7 u7nar and radius of ri(ht hand

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I ou7d 7i>e a7so to 7oo> for the @ra& of the ri(ht rist ;oint before redu%tion and after

redu%tion to see for the su%%essfu7 redu%tion bein( done< ther than that= monitor )atient

for an& im)edin( in;ur& e7sehere<

Ad9i%e to the )t re(ardin( ho to %arr& on dai7& a%ti9it& ith the e@terna7 fi@ation on the

hand< Ad9i%e for ;oint mo9ement to )re9ent stiffness of ;oint< Arran(ed for f3u) 7ater on

to see for the bone union<

Start rehabi7itation ear7&

Co&p'icatio(

Ear7& %om)7i%ation that mi(ht o%%ur in this %ase is

1G Neuro9as%u7ar in;ur& e@)e%ia77& u7nar and median ner9e and u7nar and radia7

arter&

!G Com)artment s&ndrome or im)edin( %om)artment s&ndrome< -oo> for si(n and

s&m)toms durin( hos)ita7iation

"G Infe%tion at the side of ound

-ate %om)7i%ation that mi(ht o%%ur in this %ase is

1G De7a& union or ma7 union

!G Infe%tion 7ead to osteom&e7itis and se)ti% arthritis

"G Can 7ead to ;oint deformit&= se%ondar& osteoarthritis

4G Sur(i%a7 %om)7i%ation 7i>e hemorrha(e durin( o)eration

'G +ra%ture at the site of )in insertion

5G Infe%tion )ost sur(er&

Disc)ssio(

.usti7o %7assifi%ation of o)en ound mana(ement

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