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  • Kompre Ortho TN Noviar

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    Gordon Manurung
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    1. A female patient was admitted to the hospital on December 3, 2014 with diagnoses of a closed fracture of the left tibia, a closed fracture of the right clavicle, and a laceration on her left hand. 2. She underwent surgery to insert rods (ORIF) in her right clavicle and left tibia. 3. On follow up the next day, she reported pain in her left leg when moved and pain in her right shoulder, with examination finding limited but active range of motion of both injuries.

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    Kompre Ortho Tn Noviar

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    1. A female patient was admitted to the hospital on December 3, 2014 with diagnoses of a closed fracture of the left tibia, a closed fracture of the right clavicle, and a laceration on her left hand. 2. She underwent surgery to insert rods (ORIF) in her right clavicle and left tibia. 3. On follow up the next day, she reported pain in her left leg when moved and pain in her right shoulder, with examination finding limited but active range of motion of both injuries.

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    3 views8 pages

    Kompre Ortho TN Noviar

    Uploaded by

    Gordon Manurung
    1. A female patient was admitted to the hospital on December 3, 2014 with diagnoses of a closed fracture of the left tibia, a closed fracture of the right clavicle, and a laceration on her left hand. 2. She underwent surgery to insert rods (ORIF) in her right clavicle and left tibia. 3. On follow up the next day, she reported pain in her left leg when moved and pain in her right shoulder, with examination finding limited but active range of motion of both injuries.

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    of 8

    KOMPRE ORTHOPEDI

    05 Desember 2014

    BOUGENVILLE 2 BED 3

    Bougenville 2 Bed 3
    Tn. Noviar Anis
    41.15.06.00

    Tanggal masuk
    : 03 Desember 2014
    DPJP : dr. Wendy Hendrika, SpOT
    Dokter konsul
    :Diagnosis pra bedah
    :
    Closed Fraktur 1/3 medial os tibia sinistra tanpa gangguan NVD
    Closed Fraktur 1/3 medial os clavicula dextra tanpa gangguan NVD
    Vulnus Laceratum Manus sinistra

    Diagnosis pasca bedah


    :
    Post ORIF Os Clavicula Dextra a. i. Closed Fracture clavicula dextra
    Post ORIF Tibia sinistra a.i Closed Fracture tibia 1/3 midshaft
    sinistra
    PH : 1
    PO : 0
    Sikap
    :
    1. Observasi TD, Nadi, suhu, RR
    2. Diet : bebas bila sadar penuh, BU + Flatus
    3. IVFD : I RL+III Tofedex /24 jam
    4. MM/ Terfacef inj 2 x 1 gram
    Ranitidine inj 2 x 1 amp
    5. Pasang armsling
    6. Foto Rontgen kontrol clavicula dextra dan cruris sinistra

    Follow up 04/12/2014
    s/ nyeri kaki kiri bila digerakkan dan nyeri bahu kanan
    o/ ku : tss, e4m6v5
    td 110/70, n : 80, rr: 24, s: 36,5
    toraks dbn
    abdomen dbn
    status lokalis
    regio cruris sinistra
    regio clavicula regio manus sinistra
    L : Hematom (+)
    Luka tertutup
    dextra
    F : nyeri (+)
    verband, darah (-),
    L : Jejas (-)
    pus (-), ROM : aktif,
    F : nyeri (+)
    M : terbatas
    crt< 2, akral hangat M : Aktif terbatas

    Pemeriksaan Laboratorium
    03/12/2014
    Pemeriksaan

    Hasil

    Satuan

    Normal

    Hb

    13.4

    gr/dl

    14-16

    Leukosit

    12,9

    Ribu/ul

    5-10

    Hematokrit

    41,7

    40-48

    Trombosit

    275

    Ribu/ul

    150-400

    Natrium

    143

    Mmol/L

    136-145

    Kalium

    3.6

    Mmol/L

    3.5-5.1

    Clorida

    106

    Mmol/L

    99-111

    Masa
    Pendarahan

    1.30

    menit

    1-3

    Masa
    Pembekuan

    14

    menit

    10-16

    Masa Protrombin
    Kontrol
    Pasien

    13
    14

    Detik
    Detik

    10-16
    10-16

    Ureum darah

    17

    Mg/dl

    15-45

    0.88

    Mg/dl

    0.70-1.10

    Creatinin darah

    FOTO RONTGEN

    Thorax photo 3.12.14

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