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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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