STATUS PASIEN ORTHOPAEDI

IDENTITY
NAME : Ilmiyati Khasanah
AGE : 20 years old
NO. MR : 489874
ADDRESS : Pekalongan

CHIPS OF COMPLAIN : Pain in right arm

MECHANISM OF INJURY :

by a truck from the opposite direction when she was riding a motorcycle in Sukorejo. At that time, the patient was about to pass the ca
CAR ACCIDENT : (tanda centang)
MOTORCYCLE : √ (tanda centang)
BICYCLE : (tanda centang)
WALK : (tanda centang)
HOME : (tanda centang)
INDUSTRY : (tanda centang)

PHYSICAL EXAMINATION :
AIR WAY : She can speak clearly → Airway clear
BREATHING : RR = 20x/minute, regular, there's no chest retraction, adequate
CIRCULATION : BP = 110/64 mmHg, HR = 100x/minute, regular, adequate
DISABILITY : Pupil isokor Ø 3 mm/3mm, pupil reflex (+/+)
GCS : E4M6V5 GCS=15

LOCAL STATUS : Right brachii

LOOK
Open fracture, the skin around
: the wound looks blackish, swelling (+), deformity (+), angulation (+), shortening (+), pain in a
FEEL Pain if it's touched
: (+), palpable radial artery pulsation (+), palpable ulnar artery pulsation (+), capillary refill time <
MOVE : Pain in passive movement (+), limited ROM (+) due to pain

KLINICAL PICHERS (PHOTO:

ANTERIOR :
LAPORAN ORTHO 3.jpg
LATERAL : LAPORAN ORTHO 2.jpg

MEDIAL :
POSTERIOR (IF POSIBLE) :

RONTGEN :
AP :
LAT : LAPORAN ORTHO 5.jpg

SPECIFIC (IF NEEDED) :

THORAX PA : LAPORAN ORTHO 6.jpg
ECG (>30 YO) :
LAB : Hb, L, Tr, CT, BT / PTT, APTT, HBsAg, + Blood Sugar (>30 YO)
Hb : 11.2 g/dL ; L : 19.89 10^3/uL ; Tr : 322.000/mm3 ; CT : 4 minutes ; BT : 2 minutes 30 seconds ; HBsAg : Negative

WORK DIAGNOSTIC : Open fracture grade II of 1/3 distal right humerus comminuted oblique displaced

INITIAL PLAN / Tx :

IVFD RL 20 dpm, situational hecting, splint, inj. ketorolac 30 mg, inj. omeprazole 40 mg, inj. ATS 1500 IU, Ceftriaxon