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  • Morning Report: 9/06/2019 DM Astra

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    astra yudhaTagamawan
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    A 6-year old female patient was injured in a mercon explosion at 3pm and arrived at the hospital at 6pm. On primary survey, she was conscious with a pulse of 130 and blood pressure of 111/60. She had crush injury to her left hand with deformity, laceration, and bone exposure. CT scan showed crush injury to her left hand and open fracture of the proximal phalanx of her left thumb. The treatment plan includes debridement, pinning, worst case scenario antibiotics, and CT scan.

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    A 6-year old female patient was injured in a mercon explosion at 3pm and arrived at the hospital at 6pm. On primary survey, she was conscious with a pulse of 130 and blood pressure of 111/60. She had crush injury to her left hand with deformity, laceration, and bone exposure. CT scan showed crush injury to her left hand and open fracture of the proximal phalanx of her left thumb. The treatment plan includes debridement, pinning, worst case scenario antibiotics, and CT scan.

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    © All Rights Reserved
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    12 views10 pages

    Morning Report: 9/06/2019 DM Astra

    Uploaded by

    astra yudhaTagamawan
    A 6-year old female patient was injured in a mercon explosion at 3pm and arrived at the hospital at 6pm. On primary survey, she was conscious with a pulse of 130 and blood pressure of 111/60. She had crush injury to her left hand with deformity, laceration, and bone exposure. CT scan showed crush injury to her left hand and open fracture of the proximal phalanx of her left thumb. The treatment plan includes debridement, pinning, worst case scenario antibiotics, and CT scan.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 10

    Morning Report

    9/06/2019
    DM Astra
    Identitas Pasien
    Nama : Afif Alfiansyah
    Jenis Kelamin : Perempuan
    Usia : 6 tahun
    • Time of arrival 18.00 (9/6/2019)
    • time of accident 15.00 (9/6/2019)
    MOI

    • Primary Survei
    • MOI: Pasien terkena mercon
    •

    • A : paten (+)
    • B : nafas spontan, 22x/menit, simetris, sonor +/+, ves +/+ rh -/-, wh -/-
    • C : nadi 130x/menit reguler, TD 111/60
    • D : GCS 235, PBI 3/3 mm, RC +/+
    • E:-
    Secondary Survey
    • RPS : Pasien terkena ledakan mercon di tangan kiri.

    A:
    M:
    P:
    L: 13.00 (12-05-2019)
    E: 15.00 (13-05-2019)
    Secondary Survey
    • B1 : nafas spontan, 22x/menit, sim +/+, sonor +/+, ves +/+, rh -/-, wh -
    /-,
    • B2 : nadi 130x/menit reguler, TD 111/60
    • B3 : GCS 235 PBI 3/3 mm, RC +/+
    • B4 : BAK (+)
    • B5 : BAB (-)
    • B6 : -
    Status Lokalis
    • *status lokalis manus sinistra*
    • L: deformitas (+), laserasi (+), bone exposure (+)
    • F: nyeri (+)
    • M: ROM aktif terbatas
    Asssment :
    Crush injury manus sinistra+OF OS proximal phalang digiti 1 manus
    sinistra

    Planning :
    Debridement
    Pinning
    KIE Worst Case
    Foto CT SCAN
    Foto klinis
    CT scan

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