mekong mh ,16 agustus 2015
DESCRIPTION
Morning reportTRANSCRIPT
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Morning Conference
Minggu, 16 Agustus 2015MH/L/43 Thn
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Keluhan Utama :Luka robek pada punggung kaki kanan
Hal ini dialami pasien ± 4 jam SMRS umum dr. Pirngadi Medan, awalnya pasien sedang mengendarai sepeda motor dan tiba-tiba diserempet oleh sepeda motor lain dari arah sebelah kiri dengan kecepatan tinggi. Sehingga pasien terjatuh dari sepeda motornya.
Pingsan (-), mual (-), muntah (-).
Pasien merupakan rujukan dari rumah sakit H. Kumpulan Pane Tebing Tinggi.
RPO: inj. Ceftriaxone, inj. Ranitidin, inj. Ketorolac, inj. Kalnex, inj. Tetagam.
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PRIMARY SURVEY
Airway : ClearBreathing : Spontan, RR : 24x/menitCirculation : Akral hangat, Pulse: 92x/menit
Blood Preasure : 130/80 mmHgDisability : GCS 15Exposure : Secondary survey
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SECONDARY SURVEYKepala • Mata : Pupils isokor (R=L), conjungtiva anemis (-/-), sklera ikterik (-) • T/H/M : Dalam batas normal• Leher : Dalam batas normal
Thorax• Look : Simetris, lesi (-)• Listen : Vesiculer (R=L)• Feel : Sonor dikedua lapangan paru
Abdomen • Look : Simetris, lesi (-)• Listen : Peristaltik (+) N• Feel : Soepel
Genitalia : Laki-laki, dalam batas normal
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Status lokalisata
Extremitas• Atas
Look : Luka robek di phalanx distal digiti III dextra (sudah terjahit)
Feel : Pain (+), NVD (+)
Move : ROM (+) Normal, DOF (+) ↓
• Bawah
Look : Luka robek 11x9cm di dorsum pedis dextra, dasar otot dan tulang, pinggir tidak rata, darah (+)
Feel : Pain (+), NVD (+) ↓
Move : ROM (+) ↓, DOF (+) ↓
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Foto Klinis
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Foto Klinis
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Photo Thorax AP
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Foto Manus (D)
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Foto Pedis (D) AP/Obliq
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Laboratorium (16/8/2015)
• WBC/ HGB/ HCT/ PLT : 23.400/ 12,8/ 37,7/ 180.000
• Neu : 85,1%• KGD Adr : 336 mg/dl• Na/K/CL : 139/3,50/108
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Diagnosis
Crush injury o/t (R) Pedis + Lacerated wound o/t (R) Manus phalanx distal digiti III
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Terapi di IGD:• IVFD RL• Inj. Antibiotik• Inj. Analgetik
Tindakan:• Debridement• Amputasi digiti I, II pedis dextra• Skin avulsi• Pemasangan Back Slap
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Durante Op
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Durante Op
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Post Op
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