mr 25 sept 2013 spot
TRANSCRIPT
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Morning Report
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Past illness history :
Trauma -
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PRIMARY SURVEILLANCE
Airway : Clear (+), Snoring (-), Gargling (-)
Cervical (stable)
Breathing : RR 22 x/mnt, reguler
Ins: simetry/simetry, no wound, hematom (-)
Pal: simetry/simetry, tenderness (-)
Per: sonor/sonor
Aus: vesikuler/vesikuler, wheezing (-), rhonkhi (-)
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Circulation :Akral HKM
Pulse = 88 x/min, regulerCRT
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Look : - abrasion injuries at left elbow
- hematome left knee
- deformitas at femur sinistra
Feel: - pulsasi A.poplitea and left dorsalis pedis strong palpable
- tenderness at femur sin
- feel warmer at left leg than right leg
Move: - left leg ROM limited due to pain
- false movement (+)
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SECONDARY SURVEILLANCEVT : Pulse : 84 x/min RR : 20x/min BP: 120/78 mmHg
H/N : a/i/c/d -/-/-/- trakhea deviation (-), increased JVP (-),
rhinorrhea (-),ottorhea (), wound (-)
Thorax :I : symetry
P : krepitasi (-), mass (-)
P : sonor/sonor
A : ves/ves Rh-/-, Wh -/-
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Cor : S1 S2 Tunggal Murmur (-) Gallop (-)
Abdomen :
I : Flat
P : Soefl, H/L unpalpabe, VU empty, Defans
Muskular (-)
P : tymphany
A : Bowel sound (+) normal.
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Ekstremitas
Look : - abrasion injuries at left elbow
- hematome left knee
- deformitas at femur sinistra
Feel: - pulsasi A.poplitea and left dorsalis pedis strong palpable
- tenderness at femur sin
- feel warmer at left leg than right leg
Move: - left leg ROM limited due to pain
- false movement (+)
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AMPLE Allergy : -
Medication : long term use of drug (-)
Past disease : previous accident (-)
Last Meal : alkohol (-)
Event before accident : Patient ride a
motorcycle at 7.00 am and then px fall
down, struck a roadblock on left side. Px
still conscious, but felt pain at both thigh
and can not be moved.
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Ass 1
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Planning Diagnosa
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Hasil Laboratorium
Diffcount 2/1/62/29/6 (1-2/0-1/49-67/25-33/3-7)
Hematokrit 40,4 (L 40-54% P 35-47%)
Hemoglobin 13,1 (P 13,0-18 L: 14-18)
Leukosit 10.400 (4000-11000)
Trombosit 278.000 (150000-450000)
GDA 112
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Gambaran RadiologisFoto Femur Dextra AP/L
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Ass 2
Close fractur corpus femur sinistra 1/3
medial comminutive complete
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Planning Therapy
IVFD RL1500 cc/loading
DC
Inj. Ranitidine 2x50mg Inj. Metamizole 3x1 g
Splint
Konsul dr. Sp.OT
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Planning Monitoring
Vital Sign
Urin production
Pulse dan Movement Dystal EkstremityDistal
Subyektif complain
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Planning Education
Explaine to the patient about the condition
Explain to the patient about the treatment
and complication.
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