IDENTITY

Name : Mr. R
Age : 53 years old
Sex : Male
Doctor in charge : dr. Benny Murtaza, Sp.OT
Admission : april 15th 2018
 HISTORY TAKING

Chief complain : lump in left calf

Anamnesis :
Patients referrals from orthopedic complaints came with lump on
the left calf since two months before entering the hospital.
Originally just a small scratch wounds occurred later healed. After
one week of small bumps appear in the wound, and then later
became great. Other complaints such as nausea (-), vomiting (-),
normal bowel movements and urinationa is normal
The same complaint before history (-)
A history of hypertension (-), diabetes melitus disease (-)
A history of treatment (-)
 GENERAL STATE

Head : Normal
General State :
Face : Normal
Composmentis
Eye : Normal
Vital Sign :
Nose : Normal
BP : 130/90mmHg
RR : 20x/m
Ear : Normal

HR : 72x/m Neck : Normal

T : 36.8 0c Chest : Normal
 LOCAL STATE

Regio cruris left

INS : Deformitas (+), Hematom (-), swelling (-), wound (-)
PAL : pain press (-) , crepitation (-)
CLINICAL FINDING
 PLANNING OF DIAGNOSIS

1. Blood routine and blood

chemical
2. X-Ray Cruris sinistra AP/LT
 DIAGNOSIS

Bursitis kney joint

 MANAGEMENT

IVFD
Analgetic
Consult to Ortopedy
Thank You