Professional Documents
Culture Documents
I. Profile
Name
Gender
Age Address
Occupation Religion
Race
First visit
2
: Ch. R : Male : 10 y.o : Jl. Kedondong 7 No.00 RT/RW 00 Kranji, Bekasi Barat : Student : Muslim : Javanese : Thrusday, 4 Oktober 2012
shoulder Sideswipe injury on Left shoulder Hot packs as first aid on the spot Sent with familys car to ER; e. verband Shoulder X-ray were taken Seizure (-), fainted (-), Nosebleed (-), Ear bleeding (-)
Swelling (+), Bruise (+), Blood (-), Fever (-), Patient
often does sport (volleyball) History of DM (-),HT (-), Operation (-), Family (-),
4
Heart Rate
Respiration Rate Temperature General Condition Consciousness
: 120/80 mmHg : 80 x/m : 24 x/m : 36,5 oC : Tampak sakit ringan : Compos mentis, GCS E4M6V5 = 15
B. General Status
Head Neck Thorax Abdomen
Ekstremities
Dressed with Figure of 8 Bandage Bruise (-) Redness (-) Swelling (+) Open wound(-)
Feel: Deformity (+) Tenderness(+) Warm (+) Move: Limited, painful ROM on flexion and adduction
V. Supporting examination
Xray3 Oktober 2012
VI. Diagnosis
10
11
Thank You
Operation report
Pre-operative: Patient had taken a complete lab examination and was consulted to pulmonologist and cardiologist The lab results were normal without contraindicating value Patient was declared fit for operation by pulmonologist and cardiologist Patient was given informed consent and planned to be operated on Monday, October 8th 2012, 08.00 09.00 Patient was admitted to Tulip Room for pre-operative preparation
During operation:
Patient was operated on Monday, Oktober 8th 2012, 08.00-
and the planned operation is ORIF with clavicule plate & screw:
Patient lied in supine position Aseptic & antiseptic were done Identification of fracture site Incision of site in S Shape Identification of fractured bone Isolation of fractured bone from surrounding tissues Reposition of fractured bone with reduction clamps Fixation of bone with clavicule plate and screw Site of operation is sutured layer by layer
Left Clavicule Fracture, Post Operation. Pen is positioned well and steady No Complicaiton is present from radiologic and laboratoric finding Patient was allowed to go home
Thank You