laporan case igd.ppt
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7/21/2019 laporan case igd.ppt
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Morning ReportMonday, Jan 4th, 2016
RSUDZA
Team on duty
dr. i!ar"i #Jaga 1$
dr. Aa Dimyati A #Jaga 2$
dr. Muharrian%yah #Jaga &$
dr. a%ru" 'aidi #Jaga &$
dr. Adang S #Jaga 4$
dr. Ar(an A%madi #Jaga 4$
dr. )ie*o + #Jaga $
dr. M. Ta-a #Jaga 6$
dr. /(ani S #Jaga 6$
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6112
oDi%triution o( %urgery
patientRoom
1 3mergeny room patient 13 Patients
2 'o%pita"i!e 7 Patients
& ut o( "ini 6 Patients
4 Re(u%e media" ad7ie -
+a%%ed aay
Muliadi R/ LK/34 yo/ posteksplorasi retroperitoneal +insisi drainase + evaluasi
abses retroperitoneal/ rawat!"#/ P$# 1
6 'o%pita"i!e room Jeumpa 1 %&/%& bed
Jeumpa 2 %&/%& bed
Jeumpa & %&/%& bed
Jeumpa 4 %&/%& bed/8U8 % Patients
/8U % Patient
/8U 6 Patient
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3
/8U ADU9T 1'(ur)ana*/ pr/ 7 yo/ post ,raniotoi evakuasi !./ P$# 6
%'Rosiati/ pr/ 6 yo/ Post t*ra,eostoi + severe sepsis + #M 0ype / P$# %
3'2us ali/ lk/ %4 yo/ post debrideent eer2en,y + $R a'i ,rus* in)urry
pedis 5 + open ra,ture 5#/ P$# 1
4'"pik .asana*/ pr/ 7 yo/ post laparotoi a'i total e,ani,al bowel obstruksi/
P$# 3
'sail "san/ lk/ 7yo/ post ,ranie,toievakuasi !. teporal 5#/ P$# 1
6'(urala/ pr/ 66 yo/ post laparotoi eksplorasi + bypass bilio di2estive/ P$#
/8U 1'8y' Manda (ovia Ra*i/ pr/ 1% days/ *eato sub2aleal parietal 5# +aneia + ikterik/ # 1%'8y' 9ul:adi/ lk/ 14 days post eksisi *y2roa ,olli + in)' 8leoy,in intralesi a'i*y2ro a'r ,olli/ P$# 13
/8U8 1' bra*i "ar/ lk/ &% yo/ post ,raniotoi/ P$# 16%' ;lvina/ pr/ %< yo/ post ,raniotoi evakuasi #. + !K8 + . teporo
parietal + raktur linear parietal 5/ P$# 1
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+atient identity:
•(ae = 8y' saul .usna
•2e = 6 days old
•e> = ?irl
•ddress = #esa antan ke,' n2in @aya
Kab' ,e* 8esar
•MR = 1 7 64 46
•at*erAs P*one= &3<&4%6
•Bei2*t = %' 2ra
•dition tie = 13' wib
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0ie Response
Datehour
patientameto 3R
3;aminationhour
9aoratory3;aminatio
n
Radio"ogy3;amination
'ouro(
Diagno%ti%
Datehour
patient out(rom3R
D+J+
Send Re%u"
t
Send Re%u"
t
@anuary
4t* %1
13'
13' 13'3 14'3 - - 1'3
B8
1&'
B8 to(!"
#r' #ian
diCp'8
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8hie( omp"ain:
.ypersalivation
+re%enting hi%tory:
Patient was reerred by Mera>a *ospital wit* a,*ie ,oplain *ypersalivation sin,e *e born'Patient was born wit* se,tio ,aesaria andwit* pre ater pre2nan,y' .istory o (! 5+wit* idwie and ante natal ,are wit*
poly*idranion' 0*e patient wit* dyspneuater 3 day o live'
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+hy%ia" e;amination:
•Eital i2n
•?eneral ppearan,e = Poor
•u,kin2 reFe> = -
•?raspin2 reFe> = -
•!ryin2 = weakness
•Pulse = 1& beats / in
•Respiratory rates = 6 breat*s /in
•8ody teperature = 37C6 o!
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t t*e oral
• = *ipersalivation 5+
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L/ at t*e *eit*ora> re2ion
06/07/14
Thora;e;amination
Righthemithora;
9e(themithora;
/n%petion
Palpation
Perkussion
Auskultation
ietrisC tra,*ea
deviation 5-
RR = 6 beat*
/inuteRi2*t G Let
onor
Eesi,uler
de,reaseC ron,*i
5+
ietrisC tra,*ea
deviation 5-
RR =
6beat*/inute
Let G ri2*t
onor
Eesi,uler
de,rease C ron,*i
5+
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t abdoinal re2ion
• = yetri,alC distention 5+C dar,ontour 5-
#ar
•= 8owel sound 5+ norally
•P= oot*•P=0ipany 5+C liver dullness 5+
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KL(
06/07/14
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A%%e%%ment:
1'usp esop*a2eal atresia wit* distal 0;
%'Respiratory distress due to suspe,pneuonia
3'Mild to Moderate de*ydration
Management
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Management
•Position body up 4o
•$?0 was blo,kin2 $?0 was aintenan,e about <, and perored su,tion every 1 inutes
•Resus,itation
E# RL %' > % ,, G ,,/ *ours
Maintana,e Rl H % ,,/ %4 *ours
•!at*eter urine
•n)' Meropene 7 2
•n)' MetaiIol sodiu 2
•Laboratoriu e>aination
•Radiolo2y e>aination
Time Urine
#88$
14' 3
1' 3
16' 4'
17' 4'
1&'
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9aoratory re%u"t%:
• .b = 1<' 2r/dl
• B8! = 14' /ul
• 0robo,yte= %%4' /ul
• .t = 4 J
• !0 = 7 inutes
• 80 = % inutes
• odiu = 13& ol/L
• Potasiu = 3'4 ol/L
• !*loride = 14 ol/L
• 8lood 2lu,ose ad rando = &1 2/dl
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A<DA
• p. = 7'3 .2
• P,o% = 4&'3 .2
• p$% = 6 .2• .!$3 = %4' ol/L
• 0otaol !$% = %' ol/L
• 8; = -%'• aturasi $% = &7' J
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Radio"ogy Re%u"t :
8aby ?ra =
•$?0 0*
•#ilatation o 2astri,
•#istribution o air until distal
•#e>tro,ardia
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Diagno%e:
1'usp esop*a2eal atresia wit* distal 0; 50ipe !
%'Respiratory distress due to suspe,
pneuonia
3'Mild to Moderate de*ydration
4'#e>ro,ardia
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8on%u"t to +ediatri Surgery di7i%ion
•.ospitaliIe in (!"
•?astrostoy eer2en,y
•;,*o,ardio2rapy
• 0*ora,otoy anastoosis eosoa2us +devided ,olostoi
06/07/14
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perati7e report
• Perored idline in,ision
• identi:,ation 2aster
• Peror % purse strin2 suture• Peror ,*ateter 51%r insertion to
2aster
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+o%t operati7e diagno%e:
1'usp esop*a2eal atresia wit* distal 0; 50ipe ! 5!# 1 !M 3<'1
%'Respiratory distress due to suspe,
pneuonia 5!# 1 !M @17'
3'Mild to Moderate de*ydration 5!#1 !M ;&6'
4'#e>tro,ardia 5!# 1 !M%4
= "" U
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=o""o UpDate S O A P
January6th POD 1
(-) Eital i2n?eneral ppearan,e
=
oderatelyu,kin2 reFe>
= 5+Cpoor?raspin2 reFe>
= 5+C por!ryin2
= 5+C poorPulse
= 13 >beats / inRespiratory rates =4 breat*s /in8ody teperature =37C% o!po% = <J r'*eit*oraksre2ionus,ultation
vesi,ular 5+CRon,*i +
+o%t<a%tro%tomy
1'uspesop*a2ealatresia wit*distal 0; 50ipe! 5!# 1 !M
3<'1
%'Respiratorydistress due tosuspe,pneuonia 5!#
1 !M @17'
3'Mild toModeratede*ydration 5!#1 !M ;&6'
4'#e>tro,ardi
top oral intakeE# 4=1 % ,,/%4
*ours$?0 5su,tion per 1*our8ody up 4
n)' Meropene 72
n)' MetaiIolsodiu 2
$bservasion "rineout put
;,*o,ardio2ray
Prepare or 0*ora,otoy
esop*a2ealanastoosis
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+atient identity
• (ae = (ia Lisa
• 2e = 16 years old
• e> = ?irl
• ddress = #s' Bi*ni 8akon2C Ke,' ili* (ara
Kab' ,e* 0en2a*• at*erAs P*one = &%36%&%13
• MR= 1 7 6 1&
• 8ody Bei2*t = & k2• dission tie = 'B8
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Time Re%pon%e
DateTime
patientame to
3R
3;amination hour
9aoratory3;amination
Radio"ogy3;amination
Time o(Diagno%
ti%
DateTime
patientout (rom
3R
D+J+
end Result end Result
@anuaryt* %1
'
'1 '3 6'3 - - 6'3 11' to$R
#r' #iandiC p'8
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8hie( omp"aint• Pain at t*e w*ole abdoinal re2ion
+atient i""ne% hi%tory• 0*e patient reerred ro 0eken2on distri,t
*ospital to 9ainoel bidin ;er2en,y
Roo wit* a ,*ie ,oplaint pain at t*ew*ole abdoinal re2ion' nitiallyC patientpain elt at t*e ri2*t lower abdoinalre2ion or daysC % days a2o t*e patientelt pain at t*e w*ole abdoinal re2ion
and 2ettin2 worstC and t*an *e reerred toR"#9C .istory o nausea and voit 5+C*istory o ever 5+C *istory o diar*ea 5+'
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+hy%ia" e;amination>ita" %ign :
• 8lood pressure = 16/7 .2• Pulse = 11 beats/inute• Respiratory rates = %% breat*s/inute
• 0eperature = 3&o
!
9S at the adomina" region :• = yetri,alC distension 5+ inial
• = 8owel sound 5+ de,rease• P = Pain and us,ular ri2idity 5+ at t*e
lower uadrant• P = Liver dullness 5+C 0ypani 5+
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Digita" Reta" e;amination :• 0onus pin,*ter ani = ti2*t
• pula re,ti = ae,es 5+• Re,ti Mu,ous = oot*• Pain = 5+
• ?love = 8lood 5-C ae,es 5+'
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klinis
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E = Moderate
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E = Moderate
Mi"d 1?& Moderate 4?6 Se7ere @?10
(on opioid +ad)uvant
- !$-%- buproen- spirin-,etainop*en
$pioid +nonopioid +
ad)uvant-!odein-Propo>yp*ene-.ydro,odone-0raadol
$pioid +nonopioid +
ad)uvant-$>y,odone-Morp*ine-.ydroorp*one-entanyl
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A%%e%%ment% :
1'?eneral peritonitis due to susp'peroration o t*e appendi,itis
%'Mild to oderate de*ydration
3'epsis
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Management• top oral intake• (?0 ,lear• "rinary !at*eter
• Re*ydration =1 ,, RL• Maintana,e
E# RL %7 ,,/ %4 *our• !etria>one in) 1 2
• MetronidaIole 2 drip• MetaiIole odiu n) 1 2• Laboratory e>aination
Time Urine
#88$6' 6
7' 7
&' <
<' 11
1' 13
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9aoratory re%u"t• .b = 1'6 2r/dl• B*ite blood ,ount = 33'7 /ul• Platelet = 4&1' /ul• .t = 34 J
• !0 / 80 = 7A / %A• ?lu,ose ad rando = & 2/dl
• odiu = 141 ol/L
• Potassiu = 3'3 ol/L• !*loride = 13 ol/L
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Diagno%ed
1'?eneral peritonitis due to susp'peroration o t*e appendi,itis
%'epsis
8on%u"t to pediatri %urgerydi7i%ion
• Laparotoy e>ploration +ppende,toy eer2en,y
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perati7e report :
•Perored idline abdoinal in,ision
• 0*ere was ad*esion peroedad*esiolisis
• 0*ere was serous purulent Fuid 3 ,,
•#ire,t e>ploration to ,ae,uC denti:edappendi>C retro ,ae,alC ere,tilC oedeClen2t* & , wit* ikroperoration at ape>o appendi>
•ppendi> was release ro essoapendi> Ca' appendi,ularis li2ation and peroredappende,toy and duble li2ation suture sent to P
•!avu abdoen rinse wit* noral salineuntil ,lean
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+o%t operati7e diagno%e
1'?eneral peritonitis due to susp'peroration o t*e appendi,itis 5!#1 !M !1&'
%'Mild to oderate de*ydration 5!#1 !M ;&6'
3'epsis 5!# 1 !M 41'<
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=o""o up :
Date S A + @anuary
6t* %16
P$# 1
Pain
5-
Eital i2n =
8P = 11/7 .2RR = %% breat*s/nt
Pulse = &4 beats/nt
0= 36C&A!
L/ at t*e abdoinalre2ion =
= wound operation 5+
dry
= 8owel sound 5+
P= Pain 5-
P= Liver dullness 5+
"rine 1 ,, / *
Post laparotoy
e>ploration +appende,toy
eer2en,y1'?eneral peritonitis dueto susp' peroration ot*e appendi,itis 5!# 1
!M !1&'%'Mild to oderatede*ydration 5!# 1 !M;&6'3'epsis 5!# 1 !M41'<
• #iet M
• E# RL 1,,/ %4 *our
• !etria>one in) 12
• MetronidaIole 2 drip
• MetaiIole
odiu n) 1 2
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+atient identity
•(ae = alin
•2e = 4 years old•e> = Male
•ddress = #s Reudep MeulayuC
Ke,' 8andar #uaC Kab' Pidie @aya•!M = 1 7 63 7
•P*one = &%%433%%143
•#rivin2 Li,ense = +•dission tie = 11'3 M
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0ie Response
Datehourpatientame to
3R
3;amination hour
9aoratory3;amination
Radio"ogy3;amination
'our o(Diagno%t
i%
Datehourpatie
ntout
(rom3R
D+J+
Send Re%u"t Send Re%u"t
@anuary4t* %1
11' 3
11'4 1%' 13' 1%' 13' 13' %' to$R
#r'MusliCp8'K8#
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8hie( 8omp"aint
Pain at t*e abdoinal re2ion
'i%tory o( pre%ent i""ne%%
Patient was reerred ro i2li distri,t*ospital to 9ainal bidin eer2en,y roo
wit* a ,*ie ,oplaint pain at t*eabdoinal re2ion or 4 *ours a2o' 0*epatient was ridin2 otor,y,le wit*out*eletC suddenly *e stru,ked by anot*er
otor,y,le ro opposite o *i and *ewas elt under2round' 0*ere was no *istoryo de,rease o ,ons,iousnessC voitin2 andnausea'
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+hy%ia" e;amination
+rimary Sur7ey
• = !lear•8 = pontaneousC RR= %% breat*s/ inute
•! = 8P=11/7 .2C Pulse < beats/inuteC 0 = 36C&A!
•# = ?! 1 5;4 M6 E C iso,*ori, pupilN3/3C
•; =
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S9 at Adomina" region
• = yetri,alC distension5-C *eatoe
5- e>,oriated wound 5-C
• = 8owel sound 5+ norally
•P = Mus,ular ri2idity 5-C Pain 5+
•P = 0*ypaniC liver dullness 5+
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#i2ital re,tal e>aination =
•pin,ter ani = 0i2*t
•pulla re,ty = ;pty
•Mu,osa = oot*
•Pain = 5-
•?love = e,es 5-C blood 5-C u,ous5-
Seondary Ser7ey
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Seondary Ser7ey
'ead in noral liit
e* in noral liit
Thora; in noral liit
Adomen
• = yetri,alC distension5- e>,oriated
wound 5-C *eatoe 5-• = 8owel sound 5+ norally
•P = Mus,ular ri2idity 5-C Pain 5+
•P = 0*ypaniC liver dullness 5+Upper e;tremity in noral liit
9oer e;tremity in noral liit
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Klinis
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E = Moderate
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E = Moderate
Mi"d 1?& Moderate 4?6 Se7ere @?10
(on opioid +ad)uvant
- !$-%- buproen- spirin-,etainop*en
$pioid +nonopioid +
ad)uvant-!odein-Propo>yp*ene-.ydro,odone-0raadol
$pioid +nonopioid +
ad)uvant-$>y,odone-Morp*ine-.ydroorp*one-entanyl
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A%%e%%ment
8lunt abdoinal in)ury wit* stable
*eodynai,
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Management
•$% 6 lt via nasal ,anule
•(?0 ,lear
•E# RL % drips/inute
•!etria>one n) 12•Ketorola, in) 3 2
•"rinary ,at*eter yellowis* 53 ,,
•Laboratory e>aination•Radiolo2y e>aination
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9aoratory re%u"t%: #12.00 )/$
•.b = 1%' 2r/dL
•B*ite blood ,ount= 11'7/ul•Platelet = %43'/ul
•.eato,rit = 37J
•!0 = <A•80 = %A
•"reu = 37 2/dL
•!reatinine = '7 2/dL•8lood 2lu,ose ad rando= 17 2/dl
ollow up
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ollow up'ou
r+
#mmhg$
'R#;B$
RR#;B$
Urineutp
ut
Managemen
1%' 11/7 < %% 4 observation
13' 11/& 1 %% 4 Result blood ;>a=•.b = 1%' 2r/dL•B*ite blood ,ount = 11'7/ul•Platelet = %43'/u
14' 11/7 11 %3 44 erial 8lood routin e>a
1' 1/7& 11 %% 46 0 ;>aination0 5+C ree Fuid at t*e ,avu abdoenand paravesi,aC suspe,t splee n rupture
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'our
+#mmh
g$
'R#;B$
RR#;B$
Urineutp
ut
Managemen
16' &/6 1% %4 4& Resus,itationRL 1 ,, + ,olloid ,,
Result blood e>a = .b= &'7 2r/dL
B*ite blood ,ount= %3'6/ulPlatelet= 1&&'/ul.eato,rit = %7 J
17' 1/7 11 %1 4 Prepare transnsusion
Pain 5+ in,rease at t*e w*ole abdoinalre2ion = #istention 5+C inial= 8owel sound 5+P= #eans abdoinal 5+P = typani
1&' </67 11 %4 Prepare to $peratin2 roo
1<' </7% 13 %% 46 0ranussion PR!
%' </76 14 %3 44 $peratin2 roo
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0
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"? 0
•ree luid 5+ at parapelvi,a and,avu abdoen
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Diagno%e =
1'8lunt abdoinal in)ury wit* unstable
*eodynai, due to susp' rupture solidor2an
%'yok *eorra2i, 5 2rade
50ransient respon res,usitation
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8on%u"t to Dige%ti7e %urgerydi7i%ion =
•Laparotoy ;>ploration eer2en,y
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perati7e Report•Peritoneu was openC Few out blood
about 1 ,,•;>ploration to splen rupture at pedi,leand *illus o spleen 52rade E•Perored plene,toy
•8leedin2 ,ontrol•ndenti:,ation ro 0reiIt Li2 to distalt*ere was in noral liit•bdoinal ,avity was irri2ated wit*
war noral saline•Bound operation ,losed by priarysutured wit* % tube drain
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#urante op
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Post operative dia2nose
1' ?eneral peritonitis due to bluntabdoinal in)ury wit* unstable*eodynai, due to internal
bleedin2 due to rupture o splen2rade E 5!# 1 !M 36'
%' yo,k *eorra2i, 2rade 5!# 1
!M 0&1'
=o""o up
@anuary6t* %16
Pain 5- ?eneral ,ondition =?ood
+o%t9aparotomy C
#iet 1& k,alE# RL 3
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6t* %16
P$# %
?ood!ons,iousness = lert
8P= 11/7 .2
Pulse = < beats/ntRR = %% breat*s/nt 0= 36'A!Adomen
• = yetri,alCdistension5-
e>,oriate wound 5-Cdar ,ountour 5-Cdar staiun2 5-• = 8owel sound 5+norally•P = Mus,ular ri2idity
5-C Pain 5+•P = 0*ypaniC liverdullness 5-
•#rain = 3 ,,seroue *eorra2i,
•#rain = ,,
9aparotomy CSp"enetomyDue to
1'?eneralperitonitis due toblunt abdoinalin)ury wit*unstable*eodynai,
due to internalbleedin2 due torupture o splen2rade E 5!# 1!M 36'%'yo,k
*eorra2i, 2rade 5!# 1 !M 0&1'
E# RL 3drip/ntn)' !etria>one12r/ 1% *ours
n)' Ketorola, 32/ & *ours
Lab.b H 7C& 2r/dl
Leukosit 1'3u/l
0ransusion
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+atient identity
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+atient identity
•(ae = usi
•2e = %1 years old•e> = ?irl
•ddress = ?apon2 Mulia Ke,' Kuta
la Kota 8anda ,e*•MR = 1 7 64 67
•P*one = &%%4&34%%6
•#rivin2 li,ense = 5-
•dission 0ie = 4'3 PM
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0ie Response
Datehour
patientame to
3R
3;aminationhour
9aoratory3;amination
Radio"ogy3;amination
'our o(Diagno%t
i%
Datehour
patientout
(rom3R
D+J+
Send Re%u"t Send Re%u"t
@anuary4t* %1
16'3
16'3 17' 1&' 17'3 1&' 1&' @anuaryt*
13' to$R
#r'ariIalRa*a
nCp'$0
8hie( omp"aint
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8hie( omp"aint
Pain and diO,ult to ove o t*e let oot
+re%enting hi%tory
0*e patient ,ae to 9ainoel bidineer2en,y roo wit* ,*ie ,oplaintpain and diO,ult to ove o t*e ri2*toot or % *ours a2o' 0*e patient wasridin2 otor,y,le wit* *eletC suddenly
s*e stru,ked by be,ak ro be*ind' 0*ere was no *istory o de,rease o,ons,iousnessC voitin2 and nausea'
+hy%ia" e;amination :
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+hy%ia" e;amination :+rimary %ur7ey• = !lear
•8 = pontaneousC RR G % breat*s/inute•! = 8P 1%/7 .2C Pulse = <beats/inute•# = ?! G ;4 M6 E G 1C iso,*ori, pupil
53/3C li2*t reFe> 5+/+
L/ at t*e let oot•Look = deority 5+C swellin2 5+C
la,erated wound 5+ siIe 1 ,Cbone e>pose 5+•eel = Pain 5+C (E# 5-•Move = R$M liited at t*e let oot
S d
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Seondary %ur7ey :• .ead and ne,k = in noral liit
• 0*ora> = in noral liit• bdoinal = in noral liit• "pper ;>treity = in noral liit• Lower ;>treity =
L/ at t*e let oot
• Look = deority 5+C swellin2 5+Cla,erated wound 5+ siIe 1 ,C
bone e>pose 5+C• eel = Pain 5+C (E# 5-
• Move = R$M liited at t*e let oot
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E = Moderate
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Mi"d 1?& Moderate 4?6 Se7ere @?10
(on opioid +ad)uvant
- !$-%- buproen- spirin-,etainop*en
$pioid +nonopioid +
ad)uvant-!odein-Propo>yp*ene-.ydro,odone-0raadol
$pioid +nonopioid +
ad)uvant-$>y,odone-Morp*ine-.ydroorp*one-entanyl
A%%e%ment
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A%%e%ment$pen ra,ture o t*e let oot
Management :•top oral intake•obiliIation
•E# RL % drips/inutes•n)' !eaIoline 1 2r•n)' Ketorola, 3 2•n)' 0eta2a % "•Laboratory e>aination
•Radiolo2y e>aination
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9aoratory re%u"t
– .8 = 1%'& 2/dl – .0 = 3< J
– B*ite blood ,ount = 11'4 u/l
– Platelet = 331' u/l
– "reu = %< 2/dL
– !reatinine = '63 2/dL
– !0= 7A
– 80= %A
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Radio"ogy e;amination9e(t =oot A+"i-ue :
•#is,ontinuity o bone at t*e 4t* and t* let etatarsal
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Diagno%i%$pen ra,ture o t*e let 4t* t* etatarsal
8on%u"t to rthopedi %urgery
di7i%ion:• #ebrideent + K Bire
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perati7e Report
•Perored debrideent wit* noralsaline + pero>ide + povidone iodine
•denti:ed ra,ture side at t*e bone ot*e 4t*C t* let etatarsal
•Perored reposition and :>ation wit*K- wire at t*e t*e 4t*C t* let etatarsal
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+o%t perati7e Diagno%e:
$pen ra,ture o t*e let 4t* and t* etatarsal o t*e let oot 5!# 1 !M
<%'3
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D t S O A P
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=o""o Up
Date S O A P
Jan 6th 2015
POD1
Pain (+)
decrease
General Cnditin !"d
#P ! 110/70 $$h"%& ! '0/$inte&& ! 22 /$inte* ! 7 C ,/- at the le.t .t
re"in- ! "ae dr ! 3D () ! &O li$ited
+o%tderidement
C )ire$pen ra,tureo t*e let 4t* and t* etatarsal ot*e let oot5!# 1 !M<%'3
• 3D &- 20dris/$inte
• n89 Ce.aline1 "r/12
hrs• n89 :etrlac
0 $"/ ;hrs
<nd careOt .. clinic
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+atient identity
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y
•(ae = adli
•2e = 46 years old•e> = Male
•ddress = #esa Piyeun2 #atu Ke,'
Montasik Kab' ,e* 8esar
•MR = 1 7 64 47
•P*one = &%63%36%•#rivin2 li,ense = 5+
•dission 0ie = 1' PM
0ie Response
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0ie Response
Datehour
patientame to
3R
3;aminationhour
9aoratory3;amination
Radio"ogy3;amination
'our o(Diagno%t
i%
Datehour
patientout
(rom3R
D+J+
Send Re%u"t Send Re%u"t
@anuary6t* %113'
13'1 13'3 14'3 13'4 14'3 14'3 %' to$R
#r'ariI
alRa*
anCp'$0
8hie( omp"aint
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Pain and diO,ult to ove o t*e let oot
+re%enting hi%tory
0*e patient reerred ro @ant*o distri,t.ospital ,ae to 9ainoel bidin
eer2en,y roo wit* ,*ie ,oplaintpain and diO,ult to ove o t*e let ootor 4 *ours a2o' 0*e patient was ,lib a,o,onut treeC suddenly *e elt down and
*is le2 *it t*e 2round :rst' 0*ere wasno *istory o de,rease o ,ons,iousnessCvoitin2 and nausea'
+hy%ia" e;amination :
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+rimary %ur7ey• = !lear
•8 = pontaneousC RR G % breat*s/inute•! = 8P 1%/7 .2C Pulse = <beats/inute•# = ?! G ;4 M6 E G 1C iso,*ori, pupil
53/3C li2*t reFe> 5+/+
L/ at t*e let ankle )oint•Look = deority 5+C swellin2 5+Cla,erated wound 5+ siIe 1 ,Cbone e>pose 5+•eel = Pain 5+C (E# 5-•Move = R$M liited at t*e let oot
Seondary %ur7ey :
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Seondary %ur7ey :• .ead and ne,k = in noral liit
• 0*ora> = in noral liit• bdoinal = in noral liit• "pper ;>treity = in noral liit• Lower ;>treity =
L/ at t*e let ankle )oin
• Look = deority 5+C swellin2 5+Cla,erated wound 5+ siIe 1 ,C
bone e>pose 5+• eel = Pain 5+C (E# 5-
• Move = R$M liited at t*e let oot
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E = Moderate
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Mi"d 1?& Moderate 4?6 Se7ere @?10
(on opioid +ad)uvant
- !$-%- buproen- spirin-,etainop*en
$pioid +nonopioid +
ad)uvant-!odein-Propo>yp*ene-.ydro,odone-0raadol
$pioid +nonopioid +
ad)uvant-$>y,odone-Morp*ine-.ydroorp*one-entanyl
A%%e%ment
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$pen ra,ture dislo,ation o t*e let ankle )oin
Management :
•top oral intake
•obiliIation
•E# RL % drips/inutes
•n)' !eaIoline 1 2r
•n)' Ketorola, 3 2
•n)' 0eta2a % "•Laboratory e>aination
•Radiolo2y e>aination
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9aoratory re%u"t
– .8 = 14'7 2/dl – .0 = 44 J
– B*ite blood ,ount = %6'& u/l
– Platelet = %&6' u/l
– "reu = %% 2/dL
– !reatinine = 1'6 2/dL
– !0= 7A
– 80= %A
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Radio"ogy e;amination
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Radio"ogy e;amination9e(t +edi% A+"i-ue :
•#is,ontinuity o t*e let ankle )oin
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Diagno%i%
$pen ra,ture dislo,ation o t*e lettibiotallar )oin
8on%u"t to rthopedi %urgerydi7i%ion:
• #ebrideent + reposition
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perati7e Report
•Perored debrideent wit* noralsaline + pero>ide + povidone iodine
•Perored reposition and redu,tion
•Perored ba,kslab
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+o%t perati7e Diagno%e: $pen ra,ture dislo,ation o t*e lettibiotallar )oin 5!# 1 !M &%'1
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Post op
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Post op
• $pen ra,ture dislo,ation o t*e lettibiotallar )oin 5!# 1 !M<%'1
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Date S O A P
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=o""o Up
Jan 6th 2016
POD1
Pain (+)
decrease
General Cnditin !"d
#P ! 110/70 $$h"%& ! '0/$inte&& ! 22 /$inte ,/- at the le.t .tre"in
- ! "ae dr ! 3D () ! &O li$ited
+o%tderidement
C repo%i%i
$pen ra,turedislo,ation ot*e lettibiotallar )oin5!# 1 !M&%'1
• 3D &- 20dris/$inte
• n89 Ce.aline1 "r/12hrs
• n89 :etrlac0 $"/ ;hrs
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