STUDENT NAME SITI NURSAKINAH BINTI MD
JUSOH
ID MATRIC DMA 2011-3176
SUBJECT ORTHOPEDIC
CODE SUBJECT MPGS 2051
TOPIC CLOSE FRACTURE
SUBMITTED DATE 5 JUNE 2023
CLERKING CASE 1
YEAR 3
SEMESTER 5
BATCH 16
DEPARTMENT ORTHOPEDIC WARD & CLINIC
PLACEMENT HOSPITAL MELAKA
CLINICAL INSTRUCTOR MADAM INSYIRAH ROSLAN
CLINICAL CASE CLERKING AND GENERAL MANAGEMANT FORM
——————————————————————————————————
Patient Gender : Male ( ) Female ( ) R/N : 526082
Patient Race: Malay ( ) Chinese ( ) Indian ( ) Age : 21 years old
Others ( )
Date / Time : 30 May 2023/ 9.30 AM Occupation : Student
Out Patient case ( ) Emergency case ( ) In Patient (ward) ( )
Date & Time Admission : 30 May February 2023 / 9.30 AM
Date & Time Discharged : -
On Examination :
Weight : 59kg Height :179cm BMI : 34 kgm 2
Vital sign :
BP: 107/56mmHg Pulse Rate : 79/min Resp.Rate : 25 breaths/min
Temp : 35.8c Pain Score : 3/10 SPO2 : 98%
If Emergency :
GCS Score : 15 SPO2 : 98 ECG : Normal sinus rhythm
*Chief Complaint(s).
(Quote the patient’s own word)
• Pain in the left leg and abdominal pain
*Present Illness.
(Location, Quality, Quantity or severity, Timing, including onset, duration and frequency, Setting in which they
occur, Aggravating and relieving factor, Associated manifestations)
• Involved in a vehicle accident at 4.00 pm on 25 May 2023 .
• The motorbike hit the car from the opposite direction and fell hard and flew away.
• Fall in prone state.
Current medical history:
• Pain in the left leg and abdominal pain
• When arriving at the emergency unit, the patient can breathe, can follow instructions, pink,
conscious, tender cervical area, short neck, obesity weight estimated at 140kg
*Past History
Medical History
eg; diabetes, hypertension, hepatitis, asthma, food and drug allergic, HIV), with date of onset, information about hospitalization
with date.
• The patient does not have any past medical problems.
• The patient admits not having any allergies to food or food medicine.
• Social history.
• The patient admitted to smoking at least four sticks a day.
• The patient is not involved in alcohol and drug consumption
Surgical History
(date, indication and types of operation)
• The patient never underwent any surgery
Obstetric / Gynecological History
(obstetric history, menstrual history, birth control, sexual preference, any concerns about HIV infection)
• NA
Psychiatric History
(date, diagnoses, hospitalization and treatment)
• NA
*Family History.
Immediate relative, Outline or diagram, Specific Illness and etc.)
*Personal and Social History.
(Occupation, Last year of school, Life experiences, Lifestyle habits, etc.)
• Does not smoke, drink alcohol or take illicit drugs.
*Review of system.
(Head to toe, start with general question, then to specific question and etc.)
About the following subjects:
General. Respiratory. Musculoskeletal.
Skin. Cardiovascular. Psychiatric.
Head, Eye, Ears, Nose, Throat (HEENT) Gastrointestinal. Neurologic.
Neck. Urinary. Hematologic.
Breast. Genital. Endocrine.
Peripheral vascular.
GENERAL EXAMINATION
• The patient is conscious
• GCS: Eye-4, Verbal-5, Motor-6.=15
• Blood pressure 107/56
• Pain Score is 3.
• Eyes- no bleeding, in normal condition, no jaundice.
• Ears, nose - no discharge coming out.
• Repala - no injuries
• Chest - the shape of the chest is normal, symmetrical and without any defects
• Hands - no injuries
• Abdomen - No abnormalities seen, no wounds or scars.
• Leg - swelling on the right femur and left tibia. can move the big toe and scan the
sensor, puncture wound on the right leg
Auscultation
• cardiovascular system - No murmur
Examination of the Respiratory System
Abdominal Section:
Inspection: There are no surgical scars and wounds
Percussion: Sound dullness
Auscultation: Bowel sounds can be detected
Abdominal palpation:
Urinary and genital parts
• No abnormality was detected.
• No wounds, scars or defects.
PHYSICAL EXAMINATION
(General Survey / General Inspection, Vital Signs, Skin, Back: inspect and palpate the spine and
muscle)
OCULAR EXAMINATION
1.Upper limb
Left side
• No wounds and abrasions on the hands
• Normal Range of Motion (ROM).
• Normal touch
• Redness and slight swelling on the left hand
• Can't move the metacarpal part normally
• Slight deformity of the radial pulse can be palpated
• Capillary refill time (CPT) is normal within 2 seconds
Right side
• No wounds and abrasions on the hands
• Range of Motion (ROM) is in normal conditions Able to move the phalanx
• There is no deformity problem on the right hand, The mash touch sensor works
• Capillary refill time (CRT) is normal in 2 seconds
1.Lower limb
Right Side:
• Abnormal range of motion
• Sensory touch is normal
• Wound on the shin
Left side:
• Abnormal range of motion
• Sensory touch is normal
• There is no problem with deformity
• Wound on the thumb
Differential Diagnosis :
• Close fracture midshaft of right femur
• Experienced a fracture on the right femur
• Suffering a fracture on the left tibia
Laboratory test and result : - x-ray
Radiology test and finding : -
Diagnosis :- a) Close fracture midshaft of right femur
b) Closed fracture of midshaft of left tibia
Management and treatment :
Emergency department
1. X-ray of the left leg
2. X-ray right ankle AP view
3. X-ray knee AP view
4. X-ray pelvis
5. X-ray full right femur
6. Skin traction on the right lower limb
7. Perform a close manipulated reduction on the left tibia and install a cast
8. Treatment and surgery on big toe under LA
9. Treatment and surgery wound on the right shin
10. Immobilizer on the head
11. High flow mask 15L/min
12. IV morphine 5mg
13. Normal saline 2 pints
14. Iv cefuroxime 1.5g stat
15. Vital sign monitoring
16. Insert CPD
17. Refer to a surgeon
Nursing intervention.
• Nursing care such as diet care, personal hygiene, elimination and washing wounds while in the ward.
• RIB (rest in bed).
• Observation of the circulation chart to know the level of blood circulation in the injured area to ensure the
healing process happens quickly and avoid any complications.
• CMR is performed to correct the position of the bones.
• Administration of pethidine as an analgesic. ( 50 - 100 mgm orally, I/M, S/C )
• Administration of Flumanazile antidote. (0.5 mgm/ 5 ml injection)
• X-ray review to confirm the position of the bones after the treatment is given.
Health Education:
• Keeping cash clean.
• Do not put foreign objects into the cash.
• Not scratching the cash.
• Prevents cash from being exposed to water.
• Not opening cash yourself.
• Always make sure the cash is in good condition (not damaged/cracked)
• Immediately come to the hospital in case of a problem.
• Care of personal hygiene and a balanced diet.
• Avoid doing heavy activities.
• Come for Follow Up treatment according to the given date.
Signature :
SAKINAH
………………….
Student Name : Siti Nursakinah Binti Md Jusoh
Matric no : DMA 2011-3176
Date and time : 10 February 2023 / 10.00 am
