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1. IDENTITY
Name : NNS
Sex : Female
Age : 62 yo
No CM : 2203xxxx
Insurance : BPJS
Address : Denpasar
Phone Number : -
Admitted : 28/06/2022
Ward : WK

2. Chief Complaint
• Pain on right shoulder
Present History
• Patient complained pain on her right shoulder after slipped and fell in front of her
house 10 hours prior to admission.
• Patient was walking in front of her house, when suddenly slipped and fell to the
front, with her right arm holding her bodyweight.
• Pain like sharp pain and felt continuously.
Past History
• No history of systemic disease
History

3. Family History :
⁻ No others family member has the same problem as the patient.
Social History :
• Patient is a housewife, and a Family of Internist in Sanglah Hospital

4. Right Shoulder Region :
L: Swelling (+) around shoulder, bruise (+), deformity (+) squarring shoulder
F: Tenderness (+) proximal part humerus, humeral head palpable on anterior shoulder, radial
artery (+) palpable, CRT <2'', SpO2 99%, sensation normal
M: Active ROM Shoulder limited due to pain
Active ROM Elbow limited due to pain
Active ROM Wrist 60/70
Active ROM MCP-IP 0/90

5. Chest X-Ray AP View
Sanglah Hospital (28/06/2022)

6. Right Shoulder X-Ray AP View
Sanglah Hospital (28/06/2022)

7. Laboratory Result
Sanglah Hospital (28/06/2022)
Examination Result
Normal
Range
WBC 13.53 4.1 - 11.0
PLT 272.00 150 - 440
HGB 11.4 13.5 - 17.5
HCT 36.4 41.0 - 53.0
PPT 14.0 10.8 - 14.4
APTT 28.9 24 - 36
INR 0.99 0.9 - 1.1
Examination Result
Normal
Range
AST/SGOT 23.8 11.00 - 33.00
ALT/SGPT 18.40 11.00 - 50.00
BUN 19.60 8.00 - 23.00
SC 0.71 0.70 - 1.20
Na 142 136-145
K 4.63 3.5-5.1

8. Diagnosis:
Fracture Dislocation Right Glenohumeral Joint:
- Inferior Dislocation Right Glenohumeral Joint
- CF Right Proximal Humerus Neer 3 Part
Treatment:
Right Shoulder hemiarthroplasty

9. Right Shoulder X-ray AP View Post Op
Sanglah Hospital (04/07/2022)

10. Right Arm X-ray AP/Lateral View Post Op
Sanglah Hospital (04/07/2022)

11. Clinical Picture Post Op