laporan case igd.ppt

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$



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



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



+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



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



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'



+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!



t t*e oral

• = *ipersalivation 5+



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+



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+



KL(

06/07/14



A%%e%%ment:

1'usp esop*a2eal atresia wit* distal 0;

%'Respiratory distress due to suspe,pneuonia

3'Mild to Moderate de*ydration

Management



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&'



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



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



Radio"ogy Re%u"t :

8aby ?ra =

•$?0 0*

•#ilatation o 2astri,

•#istribution o air until distal

•#e>tro,ardia



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



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



perati7e report

• Perored idline in,ision

• identi:,ation 2aster

• Peror % purse strin2 suture• Peror ,*ateter 51%r insertion to

2aster



+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



=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



+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



Time Re%pon%e

DateTime

patientame to

3R

3;amination hour

9aoratory3;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



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+'



+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+



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+'



klinis



E = Moderate



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



A%%e%%ment% :

1'?eneral peritonitis due to susp'peroration o t*e appendi,itis

%'Mild to oderate de*ydration

3'epsis



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



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



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



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



+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'<



=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



+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



0ie Response

Datehourpatientame to

3R

3;amination hour



'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#



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'



+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

•; =



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+



#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



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



Klinis



E = Moderate



E = Moderate




$pioid +nonopioid +


$pioid +nonopioid +




A%%e%%ment

8lunt abdoinal in)ury wit* stable

*eodynai,



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



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



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



'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



0



"? 0

•ree luid 5+ at parapelvi,a and,avu abdoen



Diagno%e =

1'8lunt abdoinal in)ury wit* unstable

*eodynai, due to susp' rupture solidor2an

%'yok *eorra2i, 5 2rade

50ransient respon res,usitation



8on%u"t to Dige%ti7e %urgerydi7i%ion =

•Laparotoy ;>ploration eer2en,y



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



#urante op



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



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



+atient identity



+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



0ie Response

Datehour

patientame to

3R

3;aminationhour



'our o(Diagno%t

i%

Datehour

patientout

(rom3R

D+J+


@anuary4t* %1

16'3

16'3 17' 1&' 17'3 1&' 1&' @anuaryt*

13' to$R

#r'ariIalRa*a

nCp'$0

8hie( omp"aint



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 :



+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



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



E = Moderate






$pioid +nonopioid +


$pioid +nonopioid +


A%%e%ment



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




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



Radio"ogy e;amination9e(t =oot A+"i-ue :

•#is,ontinuity o bone at t*e 4t* and t* let etatarsal



Diagno%i%$pen ra,ture o t*e let 4t* t* etatarsal

8on%u"t to rthopedi %urgery

di7i%ion:• #ebrideent + K Bire



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



+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



D t S O A P



=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



+atient identity



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



0ie Response

Datehour

patientame to

3R

3;aminationhour



'our o(Diagno%t

i%

Datehour

patientout

(rom3R

D+J+


@anuary6t* %113'

13'1 13'3 14'3 13'4 14'3 14'3 %' to$R

#r'ariI

alRa*

anCp'$0

8hie( omp"aint



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 :



+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 :



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



E = Moderate






$pioid +nonopioid +


$pioid +nonopioid +


A%%e%ment



$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




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



Radio"ogy e;amination



Radio"ogy e;amination9e(t +edi% A+"i-ue :

•#is,ontinuity o t*e let ankle )oin



Diagno%i%

$pen ra,ture dislo,ation o t*e lettibiotallar )oin

8on%u"t to rthopedi %urgerydi7i%ion:

• #ebrideent + reposition



perati7e Report

•Perored debrideent wit* noralsaline + pero>ide + povidone iodine

•Perored reposition and redu,tion

•Perored ba,kslab



+o%t perati7e Diagno%e: $pen ra,ture dislo,ation o t*e lettibiotallar )oin 5!# 1 !M &%'1



Post op



Post op

• $pen ra,ture dislo,ation o t*e lettibiotallar )oin 5!# 1 !M<%'1



Date S O A P



=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

laporan case igd.ppt

Documents

yo post craniotomi pod

patient identity

r colli pod

nurmala pr

rosmiati pr

elvina pr

days post eksisi hygroma

icu adultnurjanah pr