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  • MR DR SHD M-4

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    Asis Fitriana
    3 просмотров11 страниц
    An 11-year-old girl named An. Yusita Naswa fell while playing and injured her left arm, with her hand supporting her body upon impact. Upon examination at the local health clinic and subsequent referral to the hospital, she was found to have an open fracture of the left supracondylar humerus, type III. Her treatment plan included cleaning and debridement of the wound, application of a splint, antibiotics, and x-rays. She then underwent further debridement and fixation with cross pins for the open fracture.

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    morning report bedah

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    An 11-year-old girl named An. Yusita Naswa fell while playing and injured her left arm, with her hand supporting her body upon impact. Upon examination at the local health clinic and subsequent referral to the hospital, she was found to have an open fracture of the left supracondylar humerus, type III. Her treatment plan included cleaning and debridement of the wound, application of a splint, antibiotics, and x-rays. She then underwent further debridement and fixation with cross pins for the open fracture.

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    © All Rights Reserved
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    3 просмотров11 страниц

    MR DR SHD M-4

    Загружено:

    Asis Fitriana
    An 11-year-old girl named An. Yusita Naswa fell while playing and injured her left arm, with her hand supporting her body upon impact. Upon examination at the local health clinic and subsequent referral to the hospital, she was found to have an open fracture of the left supracondylar humerus, type III. Her treatment plan included cleaning and debridement of the wound, application of a splint, antibiotics, and x-rays. She then underwent further debridement and fixation with cross pins for the open fracture.

    Авторское право:

    © All Rights Reserved
    Скачайте в формате PPTX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 11

    KASUS 1

    DM ASIS
    10 April 2018
    Identitas Pasien
    Nama : An. Yusita Naswa
    Usia : 11 th
    Alamat : Sumberan Karanganyar Ambulu Jember
    Waktu kejadian : 10 April 2018 pukul 10.15 WIB
    Waktu datang : 10 April 2018 pukul 14.00 WIB
    No HP : 089699977636
    SUBYEKTIF
    MOI: pasien jatuh saat bermain dengan
    lengan kiri menumpu
    PRIMARY SURVEY
    ■ A : paten, stabilisasi c spine, gargling (-), snoring (-)
    ■ B : Jejas (-) RR: 22x/menit, SpO2 98%, flail chest(-)
    retraksi (-) Sonor (+/+) Ves (+/+) rh (-/-), wh (-/-)
    ■ C : warna kulit: kemerahan, N: 105x/mnt kuat angkat,
    TD 110/70 mmHg
    ■ D: GCS 4-5-6, PBI 3mm/3mm, RC +/+
    ■ E : regio antebrachii anterior sinistra
    INITIAL ASSESSMENT
    OF regio antebrachii anterior sinistra

    INITIAL PLANNING
    ■ Debridemen dan irigasi
    ■ Pasang Spalk
    ■ Inj ceftriaxone 500 mg
    ■ Inj ATS 1500 iu
    ■ X-ray antebrachii sinistra
    SECONDARY SURVEY
    ■ A : (-)
    ■ M: (-)
    ■ P : (-)
    ■ L : 7.00 (10 April 2018)
    ■ E : 10.15 (10 April 2018)

    RPS : Pasien terjatuh saat bermain kejar-kejaran pukul


    10.15 (10 April 2018) dengan posisi lengan kiri
    menumpu badan. Kemudian dibawa ke Puskesmas
    Ambulu dan dirujuk RSD. Dr. S
    Status Generalis
    ■ Keadaan umum : CM
    ■ Kesadaran : GCS 4-5-6
    ■ Vital sign : TD : 100/60 mmHg
    Nadi : 88x/menit, regular kuat angkat
    RR : 24x/menit
    Suhu Aksila: 36,8o C
    ■ Kepala/Leher : anemis (-), ikterik (-), sianosis (-), dyspnea (-)
    ■ Thoraks : Cor = S1 S2 tunggal, e/g/m = -/-/-
    Pulmo = sim +/+, ret -/-, ves +/+, rh -/-, wh -/-
    ■ Abd : flat, BU (+), soepel, timpani
    ■ Ext : akral hangat (+/+)(+/+), edema (-/-) (-/-)
    Status Lokalis

    L : vulnus apertum (+) bone expose (-)


    deformitas (+), swelling (-)

    F : nyeri (+) skala 4, CRT < 2 dtk Spo2 97%

    M : ROM terbatas
    Assesment

    Open Fracture Supracondylar Humerus Sinistra type III


    Terapi

    ■ MRS
    ■ Inj ketorolac 15 mg
    ■ Inj ceftriaxone 500 mg
    ■ Pro Debridement + cross pinning

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