laporan jaga 8 november 2015
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Laporan jaga 8 November 2015Dokter On Site : dr. Didiet Sp.OT
dr. Agung Sp.BTKV
Residen : dr. Sun & dr. Ardo
Coass : Devi & Noval
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Rekapitulasi Pasien Pasien Operasi : 1 (Tn. DD/41 th/Open fracture genu dextra/Pro debridement)
Pasien Rawat inap : 1 (Tn. RF/24 th/Fraktur Le Fort II/Ranap B.thorax)
Pasien Rawat jalan : 1 (Ny TP/ 54 th/ Ca Mammae dex)
Pasien Pulang paksa : 3
-Ny. R/ 72 thn/ VL digiti IV & V manus sinistra
-Tn. AJ/ 22th/ Fraktur tertutup Clavicula 1/3 medial
-Tn. O/47 th/ Fraktur dinding anterior sinus maksilaris + VL superior orbita sinistra
Pasien Sisa : 2 - Ny. T / 70 th/ SAH + hipertensi grade 2 + hipokalemi - Tn. D/ 64 th/ multiple VL regio fasialis + dislokasi bahu sinistra
Pasien meninggal : 0
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Pasien Op: Tn. DD (41 thn) KU:
Nyeri pada lutut kanan sejak 1 jam SMRS
RPS:
Sejak 1 jam SMRS, os merasa nyeri pada lulut kanannya. Awalnya pasien sedang mengendarai motor, kecepatan ± 60 km/jam dan dalam keadaan mengantuk (sebelumnya minum obat batuk-pilek), lalu menyerempet pagar di sisi kanan jalan saat berbelok ke kanan, kemudian motor kehilangan keseimbangan dan akhirnya jatuh ke sisi kanan. Os memalai helm, terdapat luka robek di lutut kanan disertai nyeri. Nyeri/luka di tempat lain disangkal. RPD
Riwayat DM (+) sejak 2 thn yll, Riwayat TB (minum obat tidak teratur), riwayat hepatitis B sejak 1 thn yll.
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Primary Survey A : Bebas
B : Spontan, PR: 20x/menit
C : TD 110/70, N: 85x/menit
D : E4V5M6 (GCS = 15)
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Pemeriksaan fisik Secondary survey Keadaan umum: sakit sedang
Kesadaran: CM
Tanda vital:
◦ TD: 110/70 mmHg N : 76x/ menit
◦ PR: 20x/ menit S : 37oC
Kepala : Normocephal, jejas (-)
Mata : Konjungtiva anemis-/-, Sklera ikterik -/-, pupil isokor
THT : Sekret -/-, darah -/-
Thoraks : Simetris, Jejas (-)
Cor : BI-II reguler, Murmur (-), Gallop(-),
Pulmo : Vesikuler +/+, rhonki -/-, wheezing -/-,
Ekstremitas : Akral hangat (+), edema (-), CRT < 2” (lihat Status lokalis)
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Pemeriksaan fisikStatus lokalis regio genu dextra-Look: VL regio genu dextra uk. 3.5 x 1 cm, tampak fraktur patella bagian lateral, perdarahan aktif (-)
-Feel:
Nyeri tekan (+)
-Move:
ROM lutut kanan terbatas karena nyeri
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Laboratorium
DPL : 13.3/42/9530/150000Diff Count:
Netrofil : 84.8% Limfosit : 3.8% Monosit : 10.3%Eosinofil : 0.9 %Basofil : 0.2 %
PT/APTT : 16.5/35.6
Kontrol : 14.3/31.8
Ureum : 12 mg/dl
Kreatinin : 0.4 mg/dl
SGOT : 27 U/L
SGPT : 11 U/L
Na/Cl/K : 144/4.6/109
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Rontge Regio Genu dextra
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Rontgen thoraxSEBELUM PUNGSI SETELAH PUNGSI
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Kardio : acc, resiko sedang
Pulmo : acc, resiko sedang
IPD : acc, resiko sedang
Anestesi : Acc anestesi bila cito
ASA 3 : Efusi pleura masif post pungsi 1400 cc
Riwayat TB paru & peningkatan SGOT
rencana: Spinal anestesi
Toleransi Operasi
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DIAGNOSIS PRE-OP
◦ Open fracture Genu dextra ec KLL
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Sikap Pro Debridement dan pemasangan back slab Informed consent Puasa IVFD RL 500 ml / 12 jam Ceftriaxon 2 x 1 gr IV Ketorolac 3 x 30 mg IV Ranitidin 3 x 50 mg IV
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Laporan Operasi•Pasien terlentang diatas meja operasi dalam spinal anastesi
•Asepsis dan antisepsis daerah operasi
•Identifikasi luka, tampak debris (+), tampak fraktur pada bagian lateral Patella, tidak tampak perdarahan aktif
•Luka dicuci dg NaCl 0.9 %, H202 dan betadine, jaringan nekrotik di- debridement, Bagian fraktur tulang di debridement, debris dibuang.
•Bagian rennacum Patella dijahit primer.
•Luka dicuci dengan NaCl 0.9 %
•Luka operasi dibersihkan dan dijahit lapis demi lapis
•Kaki dipasang Back Slab
•Operasi selesai
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DIAGNOSIS POST-OP
◦ Open fracture Genu dextra ec KLL
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PRE-OP
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INTRA-OP
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P0ST-OP
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Instruksi Post Operasi Rawat inap: Cempaka Atas
Awasi TNSP
Awasi tanda perdarahan
IVFD RL 2000cc /24 jam
Ceftriaxon 2 x 1 gr IV
ketorolac 3 x 30 mg
Ranitidin 2x 50 mg IV
Diet bebas setelah sadar penuh
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TERIMAKASIH