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: (2693) dlm.HSHAS.REK.12.6/14
: Tloh Rpt.4573/2014
:
Tarikh: 30/9/2014
Lama (old):.
Jantina (Sex):
MRN: .
Lelaki (Male)
Perempuan (Female)
Tarikh masuk wad atau menerima rawatan buat kali pertama (Date of admission or receiving
treatment for the first time) : 11/8/2014
Tempat menerima rawatan (Place where patient received treatment):
Jabatan Kecemasan (Emergency Department)
Klinik Pakar (Specialist Clinic)
Wad (Ward) .
after that.
No open wounds
no seizures
No vomitting
Able to suckle and breast feed as usual after that
However mother claims that child cries out whenever she touches the both elbows
Temp (oC): 37
Posture: Lying down
SBP (mmHg): 96
DBP (mmHg): 52
Pulse rate (/min): 105
Respiratory rate (/min):26
Patient active on handling, pink
anterior fontelle normotensive
CRT< 2secs, warm and pink peripheries
Good pulse volume
Pupils: 3mm reactive bilaterally
good sucking relex
Moro;s complete
Good grasp relex
CVS: DRNM
RS: no SCR, no ICR
Clear
P/A: Soft, not tender
Not distended
Bowel sounds heard
bilateral elbows- redness present on the left>right
no bluish discolouration of limbs
child does not cry on movement of elbow joints.
No swelling
radial and ulna pulse palpable
Investigation
Bilateral radius and ulna: No fracture seen
Diagnosis (Diagnosis):
Soft Tissue Injury of left Forearm
Rawatan (Treatment):
Child was examined and x ray was reviewed by Dr. Azree
To treat as Soft tissue injury of left arm first
Bandage left forearm
TCA ortho clinic in 1 week for a repeat Xray and reassessment
Rumusan prosedur yang dijalankan ke atas pesakit (summary of procedures carried out
on patient):
Bandage of left forearm
Preskripsi ubat-ubat yang diberikan kepada pesakit (drugs and other medicaments
prescribed to patients):
No medication prescribed