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  • MR Orto 09 September 2019

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    Peter
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    This document provides a morning report on a patient named TN. HR, a 38-year-old male who presented with left forearm swelling and deformity after a motorcycle accident. The primary and secondary surveys were performed and found the patient to be stable with a Glasgow Coma Scale of 15, normal vital signs, and tender swelling over the left forearm with limited range of motion. The working diagnoses were malunion of the left clavicle and left Galeazzi fracture. A backslab was applied to the left forearm and open reduction internal fixation was planned. The patient received intravenous ketorolac and ranitidine for pain and nausea.

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    Fracture case

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    This document provides a morning report on a patient named TN. HR, a 38-year-old male who presented with left forearm swelling and deformity after a motorcycle accident. The primary and secondary surveys were performed and found the patient to be stable with a Glasgow Coma Scale of 15, normal vital signs, and tender swelling over the left forearm with limited range of motion. The working diagnoses were malunion of the left clavicle and left Galeazzi fracture. A backslab was applied to the left forearm and open reduction internal fixation was planned. The patient received intravenous ketorolac and ranitidine for pain and nausea.

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    © All Rights Reserved
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    2 views21 pages

    MR Orto 09 September 2019

    Uploaded by

    Peter
    This document provides a morning report on a patient named TN. HR, a 38-year-old male who presented with left forearm swelling and deformity after a motorcycle accident. The primary and secondary surveys were performed and found the patient to be stable with a Glasgow Coma Scale of 15, normal vital signs, and tender swelling over the left forearm with limited range of motion. The working diagnoses were malunion of the left clavicle and left Galeazzi fracture. A backslab was applied to the left forearm and open reduction internal fixation was planned. The patient received intravenous ketorolac and ranitidine for pain and nausea.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 21

    MORNING REPORT 09 SEPTEMBER 2019

    Resident in Charge :
    ////

    Dokter Muda :
    Elijah
    Rizky Khansa

    Supervisor :
    dr. Istan Irmansyah, Sp.OT (K)
    IDENTITAS PASIEN
    ▪ NAMA : TN. HR
    ▪ UMUR : 38 TAHUN
    ▪ JENIS KELAMIN : LAKI-LAKI
    ▪ ALAMAT : BURING
    ▪ NO. RM : 1145XXXX
    ▪ AGAMA : ISLAM
    ▪ PEKERJAAN : KARYAWAN SWASTA
    ▪ (DOMINAN TANGAN) : KANAN

    2
    PRIMARY SURVEY
    AIRWAY + C-SPINE CONTROL
    ▪ CEK AIRWAY  PATEN
    ▪ SUARA NAFAS TAMBAHAN (-)
    ▪ RISIKO SUMBATAN JALAN NAFAS (-)

    ▪ TINDAKAN : -
    BREATHING + VENTILATION
    ▪ NAFAS SPONTAN
    ▪ PERGERAKAN DINDING DADA SIMETRIS, VENTILASI ADEKUAT.
    ▪ RR : 18X/MENIT
    ▪ SPO2 : 98% AT ROOM AIR

    ▪ TINDAKAN : O2 10 LPM VIA NRBM


    CIRCULATION
    ▪ N : 98/MENIT
    ▪ TD : 132/69 MMHG
    ▪ AKRAL HANGAT
    ▪ CRT < 2 DETIK
    ▪ SUMBER PERDARAHAN EKSTERNA (-),
    PERDARAHAN AKTIF (-)

    ▪ TINDAKAN : -
    DISABILITY
    ▪ GCS : 456
    ▪ PUPIL BULAT ISOKOR 3 MM/3 MM
    ▪ REFLEKS CAHAYA +/+
    ▪ LATERALISASI (-)

    ▪ TINDAKAN : -
    EXPOSURE
    ▪ SUHU 36,5° C

    ▪ TINDAKAN : -
    ▪ ADJUNCT TO PRIMARY SURVEY:
    SECONDARY SURVEY
    HISTORY
    ▪ ALLERGIES : -
    ▪ MEDICATIONS : -
    ▪ PREVIOUS MEDICAL/SURGICAL SURGERY : -
    ▪ LAST MEAL : 3 JAM SEBELUM MRS
    ▪ EVENTS :
    PASIEN MENGELUH NYERI DAN BENGKAK PADA LENGAN BAWAH
    KIRI SETELAH MENGALAMI KECELAKAAN SPM VS SPM. PENGSAN (-),
    MUAL (-), MUNTAH (-). RIWAYAT JATUH DARI SEPEDA 10 TAHUN
    YANG LALU, MENGENAI BAHU KIRI, NAMUN PASIEN HANYA DIBAWA
    KESANGKUL PUTUNG.
    HEAD TO TOE EXAMINATION
    Keadaan umum :
    GCS 456 VAS skor 3-4/10
    TD = 132/69 mmHg; N 98x/menit; RR = 18x/menit; Tax = 36,5°C

    Pupil isokor 3mm/3mm


    Reflek kornea (tidak dilakukan)
    Reflek pupil (+/+)
    Kepala
    Konjungtiva anemis -/-
    Konjungtiva hiperemi -/-
    Sklera Ikterik -/-

    Leher Dbn
    Jantung :
    Inspeksi : ictus cordis tidak terlihat
    Palpasi : ictus cordis teraba di ICS V MCL Sinistra
    Perkusi : batas jantung kiri
    Auskultasi : S1 S2 single regular, murmur (-), gallop (-)

    Paru :
    Thorax
    Inspeksi : D=S
    Palpasi : D=S
    Perkusi S S
    SS
    SS
    Aus V V Rh - - Wh - -
    V V - - - -
    V V - - - -
    Inspeksi : flat
    Palpasi : soefl
    Abdomen
    Perkusi : dullness
    Auskultasi : BU (+) N

    Akral hangat
    Extremitas
    CRT <2 dtk

    Punggung Jejas (-)

    Kelamin Discharge (-)

    Rektum Discharge (-)


    STATUS LOKALIS LEFT SHOULDER:

    L : SWELLING (-)
    F : TENDERNESS (-), NVD DISTAL NORMAL
    M : ROM NORMAL
    STATUS LOKALIS LEFT FOREARM:

    L : SWELLING (+), DEFORMITY (+)


    F : TENDERNESS (+), NVD DISTAL NORMAL
    M : ROM LIMITED

    1
    1
    15
    16
    17
    WORKING
    DIAGNOSIS
    ▪ MALUNION L CLAVICLE
    ▪ CF L GALEAZZI

    1
    R. TINDAKAN

    LEFT FOREARM :
    ▪ BACKSLAB
    ▪ ORIF PLANNED

    1
    R. TERAPI

    ▪ INJ. KETOROLAC 30MG IV


    ▪ INJ. RANITIDIN 50MG IV

    2
    TERIMA KASIH

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