Pembuatan Status Pasien

8/17/2019 Pembuatan Status Pasien

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Pembuatan Status Pasien Jumat, 13 Mei 2016

SURGERY DEPARTMENT

KEPANITERAAN UMUMKEPANITERAAN UMUM

AKU!TAS KED"KTERANAKU!TAS KED"KTERAN

UNI#ERSITASUNI#ERSITAS

A!K$AIRAATA!K$AIRAAT


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1%STATUS TRAUMA2%STATUS N"N TRAUMA


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Status T&auma

Name

' Se( '

A)e ' *ea& +- N+%Re)

'Chief complaint :

History taking :

Mechanism ofinjury

:

Injury sustain :

Symptom & sign :

Examination :


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P$YSI.A! E/AMINATI"NP$YSI.A! E/AMINATI"N

P&ima&* Su&e*P&ima&* Su&e*

A:

B:

C:

D:

E:


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Se+n-a&* Su&e*Se+n-a&* Su&e*

Region :


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aboratory Result


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"RKINGDIAGN"SIS

'

MANAGEMENT '


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PROGNOSIS:

FOLLOW UP :


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N+%

Name

' .% R Se( ' Mae

A)e ' 1 *ea& +- N+%Re)

' 61 1645Chief complaint : Wound at the head

History taking : Suffered since 3 hours before admitted to the hospitaldue to traffic accident. There was no history of

unconciuosness and vomiting (-) sei!ure (-) . "riormedical care at "ang#ep $ospital

Mechanism ofinjury

: $e was riding a motorcycle with his mother as apassenger suddenly a car hit his motorcycle from behind

direction. $e fell down with his head bumped to theasphalt.

Injury sustain : $ead

Symptom & sign : Wound pain

Examination : "hysical e%amination laboratory e%amination head &Tscan


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P$YSI.A! E/AMINATI"NP$YSI.A! E/AMINATI"N

P&ima&* Su&e*P&ima&* Su&e*

A: clear

B: RR : 24 x/minutes, spontaneous, symmetric,thoraco abdominal type

C: BP : !!/"! mm#$, #R : %& x/minute, re$ular,ade'uate

D: (C) * +E4&-*., pupil e'ual 2,*/2,* mm ,

0R 1/1E: +ax. : 3&,* oC


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Se+n-a&* Su&e*Se+n-a&* Su&e*Right frontoparietal region :

: )een lacered 5ound si6e &x3cm, edema +7., hematoma +7.,bone expossed +1., acti8ebleedin$ +7.

P : enderness +1.


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aboratory Result

WBC

:

23 x 10

3

/

Na : 13! ""ol

RBC

:

3#$% x 10

%

/

& : '#1 ""ol

(GB

:

!#! )/*

Cl : 10% ""ol

(C+

:

2$#3 ,

P +

:

$!2 x 10

3

/

C+ / B+

:

!-00. / 2-00.

Bloo*

Su)ar

:

133 ")/*l

Ureu"

:

1 ")/*l

Creat

:

0#3 ")/*l

SGO+/SGP

+

:

130%/'1 u/l


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#ead C)can


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Operating Procedure

• Patient laid supine under GA

• Disinfection and draping procedure

• Identification wound, seen lacerated wound with

depress facture and cerebral expose

• Deepen 1 burr hole, next craniecto! with cnabletang, seen duraater laerated " c

• #ash wound with $acl %,& '

• (ontrol bleeding

• )titch duraater water tight• (lose the wound la!er b! la!er, a*e one drain

infus

• Operation finished


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Status N+n T&auma

Name ' Se( '

A)e ' *ea&s

+-

N+%

Re)

'

.ie;+m:aint

'

$ist+&*ta


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Physical Examination

Gene&a.+n-iti+ns

'

#ita si)n : BP : mm#$PR : x/ minutesRR : x/ minutes

: 9 C

Re$ionRe$ion


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Re$ionRe$ion

:

A :

P :

P :


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Additional Examination


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!ab+&at+&* Resut!ab+&at+&* Resut


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"RKINGDIAGN"SIS

'

MANAGEMENT '


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PR"GN"SIS

"!!" UP

'

'


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N+%

Name ' M&s% ! Se( ' emae

A)e ' 45 *ea&s

+-

N+%

Re)

' 611=43

.ie;+m:aint

'Pain at the 5hole abdomen 5all

$ist+&*ta


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Physical Examination

Gene&a.+n-iti+ns

' )e8ere illness/ 5ell nourished /conscious

#ita si)n : BP : 2!/@! mm#$PR : 2! x/ minutesRR : 24 x/ minutes

: 3@,&9 C


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Di$ital Rectal Examination

)phincter ani 5as loose< ucous 5as smooth< Ampula 5as empty< ?o palpable tumor mass<

(lo8es : ;eces +7., blood +7., slime +7.


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!ab+&at+&* Resut!ab+&at+&* Resut>. ' 22,10 ( 10

3 ?@!

Nat&ium ' 186 mm+?

R>. ' 8,=8 ( 106 ? @! Kaium ' 8, 1 mm+?

$G> ' 18,6 )?-! .+&i-e ' 10 mm+?

$.T ' 84,4 B $>sA) ' Ne)ati;

P!T ' 2== ( 103 ? @! Anti

$.#' Ne)ati;

.T ? >T ' =C00 ? 3C00 P&+teint+ta

' 5, =

>++-Su)a&

' 12 m)?- Abumin ' 2, 6

U&eum ' 2= m)?-

.&eatinin ' 0, m)?-

SG"T?SGPT

' 13=?230 u?


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ABDE? 3 P)?

ABDE? 3 P)?


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ABDE? 3 P)?


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ABDE? 3 P)?

)(


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)(Abdomen


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":e&atin) P&+e-u&e

• Patient laid supine under epidural and (A• Desin;ection drappin$ Procedure

• idline incision 2 =n$ers under Proc< yphoideus until 3=n$ers upper )P

• pen peritoneum seen redness li'uid *!! cc,

saphoni=cation +1.< denti=cation solid or$an seen noabnormallities

• Continued 5ith hollo5 8iscous exploration seen noabnormalities

• pened laser sac seen redness li'uid, saphoni;cation +1.

• Per;orm cholesistectomy

• ash peritoneal ca8ity 5ith normal saline<

• )titch the 5ound layer by layer and lea8in$ drain

• peration =nished


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P"ST"PERATI#EDIAGN"SIS

' Pe&it+nitis )ene&aisata e :an&eatitis +esist+itiasis

PR"GN"SIS

"!!" UP

'

'

ai&

#ita Si)n an- +un- eain)


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#A?F G

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