Morep Bedah b21 200115
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Transcript of Morep Bedah b21 200115
Departement of SURGERYShofa, 20 January 2015(14.00 pm- 07.00 am)
Identity
•Name : Mrs. M•Age : 55 YO•Address : Lamongan
•Anamnesis
• Chief complaint: Pain in the left arm• MOI :Patient came with pain in the left arm since 1 hours post traffic accidents complains. Patient riding motorcycle with a helmet and she was hitten by motorcycle from left side. She fell tengkurap position, pingsan (+) about 5 minute, Nausea (-), vomit (-), PTA (+), headache (-).
• History or past illness : HT (-), DM (+) since 15 years ago and routine controled and consumed glucodex 2x1.
• History of family: -
• History of sociality:- Smoke –- Alcohol –- Herbal Medicine-
• PRIMARY SURVEY• Airway :
Clear -, snoring-, gurgling-• Breathing :
I : simetric bilaterally+
A : ves/ves, rh-/-, whz-/-
P : ICS normal
P : sonor/sonor
RR : 22x/minute, SPO2= 98%
• Circuration and bleeding control :
BP : 131/80 mmHg
Pulse Rate : 28x/minute, regular
Acral : Warm and dry to touch Red
CRT : < 2 seconds• Disability :
GCS 456
Pupil round isokor 3mm, light reflex +/+
Lateralisasi -
• Exposure :• Regio Frontal dextra Vulnus abrasio• Regio maxila dextra Vulnus abrasioio• Reg Thorax Vulnus abrasio
T : 35,4°C
• Secondary Survey :– K – L :
• anemis -/-, icterik -/-, cyanosis -/-, dysp –• Oksipital sin Vulnus appertum 3x1 cm
– Thoraks :• I : pergerakan dinding dada simetris, retraksi (-), jejas (+)• P : fremitus (+), simetris• P : sonor/sonor• A : cor : reguler , S1 S2 tunggal, suara tambahan –
pulmo : simetris (+), ves /ves, rh -/-, wh -/-– Abdomen :
• I : flat, jejas (-)• A : BU (+) N• P : supel, nyeri tekan (-), Hepar lien tidak teraba,• P : timpani, timpani,
– Ekstremitas :Akral HKM, CRT <2 detik, Regio manus dextra Vulnus abrasio, Regio patela Dex et sin Vulnus abrasio, Regio anthebrachii sinistra Vulnus abrasio
Status Neurologis
• GCS : 456• Pupil equal 3 mm, LR +/+)• MotoricUpper extremit 5/5Lower Extremity 5/5• SensoricUpper extremity +/+Lower extremity +/+
Laboratory Findings• Diff count: 1/3/86/7/3• Hematocrite: 20,5• Hb 6,4 mg/dl• Leukocytes : 8300• Thrombocyte : 128.000• GDA 248• Bleeeding Time : 2’00’’• Clothing time : 9’00”
•CT-SCAN (brain window)
•CT-SCAN (bone window)
•Clue and Cue • GCS 456
• Regio humeri sinistra Vulnus abrasio et appertum
• Female, 55 yo• Pain in the left arm• Post traffic accidents • Nausea (+)• PTA (+)
•PROBLEM LIST
• Fr. Displace et regio Humeri sinistra
• Planning Dx : -• -
• Planning Tx :• Arm slim• IVFD NaCl1500cc/24 jam• Inj Remopain 1 amp iv• Inj Santagesic 3x1 amp • Inj Acran 2x50 mg• RCI extra 4 iv• Consult Sp, OT• Consult Sp.PD• Consult Sp.J
•Prognosis• Dubia ad Bonam
Education • Explaine to the family about the disease of the family, about its theraphy and intervention will be done, and also about complication and prognosis .
• Take a planty of rest
•Thank you