laporan jaga tgl 7 8 2015
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Laporan jaga
7/08/2015
Nj/Pr/19th
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Ku : kaki kiri sulit digerakTelaah : hal ini dialami sejak 5 jam sebelum masuk rumah sakit. Awalnya pasien naik sepeda motor lalu ditabrak dengan sepeda motor dari arah belakang, lalu terjatuh dengan tumpuan pada kaki kiri.Riwayat pingsan (-). mual (-) muntah (-)
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Primary SurveyAirway : clearBreathing : Spontan, RR : 20 x/i, vesicular, rh-, wh –Circulation : BP : 110/70, HR : 80x/i, akral hangatDisability : E4M6V5 (GCS 15)Environment : Undress, logroll
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Secondary SurveyKepala : tidak dijumpai kelainanLeher : tidak dijumpai kelainanThorax : tidak dijumpai kelainanAbdomen : tidak dijumpai kelainan Ekstremitas superior : tidak dijumpai kelainanEkstremitas inferior : status lokalisata
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Status Lokalisata
• Ekstremitas inferior sinistra :– Look : luka robek 2 x 2cm, irregular, dasar
subcutis, sweeling (+),deformitas (+), hematom (+)
– Feel : nyeri (+), NVD (+) – Move : ROM (+) DOF (+)
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Foto klinis
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Foto pedis
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Foto Ankle joint
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Laboratorium
Hb/Ht/Leu/tromb : 12,9/38,30/12.900/191.000KGD adr : 91 mg/dlAlbumin : 4,54Na/K/Cl : 135/ 4,1/ 105
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Diagnosis
• Closed (L) phalang proximal digiti III, IV, V complited obliq fracture
• Closed (L) malleolus lateral fibula complited obliq fracture
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TERAPI • IVFD RL 20gtt/i• Inj. ATS • inj. Analgetik• inj. Antibiotik
Tindakan di igd- Debridement + primery suture- Pemasangan back slep
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Post op
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Terima kasih