Upload
iputu-abhi-acarya-saputra
View
221
Download
0
Embed Size (px)
Citation preview
8/13/2019 morpot kita.pptx
1/17
om
Morning Shift Reportst 2013
8/13/2019 morpot kita.pptx
2/17
Ms. T ( 25 YO)
M : the left toe crushed by car
I : regio pedis sinistra digiti I
S : pain
T : motorcycle
8/13/2019 morpot kita.pptx
3/17
Primary Survey
Airway : Clear Breathing :
Insp : bruise (-), chest wall movement
symmetrical, RR 24 x/ min, hematoma (-) Pal : crepitation sub cutis (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right = left
8/13/2019 morpot kita.pptx
4/17
C = warm extremities, Pulse = 100bpm, BP 130/90 mmHg,
capillary refill time
8/13/2019 morpot kita.pptx
5/17
History of illness :
Patient came to RSU UKI with the chief complainpain on the left toe. According to the patient,
the pain felt like tingling. Patient was hit by a car
when she walked to cross the street. Her left toewas pinned down under the car tires for about 1
minute. Patient was taken to RS UKI
immediately.
8/13/2019 morpot kita.pptx
6/17
HEAD TO TOE
Eyes : pupil isochors 3mm/3 mm, centered, direct light
reflex/ indirect light reflex +/+
Ear : Bruise (-), hematoma (-)
Neck : Bruise (-), hematoma (-)
Thorax :
Insp : bruise (-), movement of chest wall symmetrical
Pal : crepitation (-), tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right = left
SECONDARY SURVEY
8/13/2019 morpot kita.pptx
7/17
Abdomen :
Ins : flat, bruise (-)
Aus : bowel sound (+) 6x/min
Pal : Supel, tenderness (-), muscular
defense (-)
Per : tympani
Extremity:
Warm extremities, cap. refill time < 2,
edema (-)
8/13/2019 morpot kita.pptx
8/17
Localized StatusRegio Pedis Sinistra Digiti I
Look : vulnus excoriation 2x1cm, active bleeding (-),
cyanosis (+), the nail almost loose Feel : tenderness (+), edema (-)
Move : active (+) passive (+)
8/13/2019 morpot kita.pptx
9/17
8/13/2019 morpot kita.pptx
10/17
Diagnosis
Closed fracture phalang distal digiti I pedis
sinistra nondisplaced
8/13/2019 morpot kita.pptx
11/17
TREATMENTWound toilet
Extraction of the nail
AntibioticAnalgetic
Antagonist H2 receptor
8/13/2019 morpot kita.pptx
12/17
Ms. M (51YO)Chief complaint : pain on the
Additional complaints :
8/13/2019 morpot kita.pptx
13/17
History of illness :
Patient came to the RSU UKI with chief complain
pain in wound trace of operation. The operation,appendectomy was done on 1st June 2013.According to her the pain felt like tingling. The
patient felt more pain when she walked. Pus (-),
blood (-), stich scar good. The pain was spread
until the back. Theres no problem with the
urinate and defecation.
8/13/2019 morpot kita.pptx
14/17
General StatusGeneral Condition : Mild Illness AppearanceGCS : E4V5M6
BP : 110/70 mmHg
Pulse : 68 bpm
Temp : 36, 3RR : 18 x/min
Eyes : pupil isochors 3mm/3 mm, centered, direct light reflex/indirect light reflex +/+
Ear : Bruise (-), hematoma (-)Neck : Bruise (-), hematoma (-)Thorax :
Insp : bruise (-), movement of chest wall symmetrical
Pal : crepitation (-), tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right = left
8/13/2019 morpot kita.pptx
15/17
Abdomen :
Ins : flat, bruise (-)
Aus : bowel sound (+) 8x/min
Pal : Supel, tenderness (+), muscular defense (-)
Per : tympani
Extremity:
Warm extremities, cap. refill time < 2,edema (-)
8/13/2019 morpot kita.pptx
16/17
DiagnosisPost appendectomy e.c appendicitis chronic
Lower right abdomen pain e.c susp. UTI
8/13/2019 morpot kita.pptx
17/17
TreatmentAnalgetic
Vitamin B12
Antagonist H2 receptor