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    Morep Trauma Gloving 270215

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    Rachma Susteriana Putri
    The document summarizes a medical examination of a 42-year-old male patient who complained of pain throughout his body, especially in his right leg, shoulder, and face, following an assault. On examination, the patient had multiple open wounds and fractures on his right forearm with bone exposure and deformity, as well as an open frontal skull fracture on the left side. Laboratory tests and imaging were ordered. The diagnosis was an open fracture of the distal right ulna and an open frontal skull fracture on the left. The patient was started on IV fluids and antibiotics and scheduled for urgent surgery.

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    Morep Trauma Gloving 270215

    Uploaded by

    Rachma Susteriana Putri
    19 views18 pages
    The document summarizes a medical examination of a 42-year-old male patient who complained of pain throughout his body, especially in his right leg, shoulder, and face, following an assault. On examination, the patient had multiple open wounds and fractures on his right forearm with bone exposure and deformity, as well as an open frontal skull fracture on the left side. Laboratory tests and imaging were ordered. The diagnosis was an open fracture of the distal right ulna and an open frontal skull fracture on the left. The patient was started on IV fluids and antibiotics and scheduled for urgent surgery.

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    The document summarizes a medical examination of a 42-year-old male patient who complained of pain throughout his body, especially in his right leg, shoulder, and face, following an assault. On examination, the patient had multiple open wounds and fractures on his right forearm with bone exposure and deformity, as well as an open frontal skull fracture on the left side. Laboratory tests and imaging were ordered. The diagnosis was an open fracture of the distal right ulna and an open frontal skull fracture on the left. The patient was started on IV fluids and antibiotics and scheduled for urgent surgery.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    19 views18 pages

    Morep Trauma Gloving 270215

    Uploaded by

    Rachma Susteriana Putri
    The document summarizes a medical examination of a 42-year-old male patient who complained of pain throughout his body, especially in his right leg, shoulder, and face, following an assault. On examination, the patient had multiple open wounds and fractures on his right forearm with bone exposure and deformity, as well as an open frontal skull fracture on the left side. Laboratory tests and imaging were ordered. The diagnosis was an open fracture of the distal right ulna and an open frontal skull fracture on the left. The patient was started on IV fluids and antibiotics and scheduled for urgent surgery.

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    You are on page 1of 18

    Department of Surgery

    February 27, 2015

    Name : Tn. S
    Age
    : 42 y.o
    Sex
    : Male
    Address : Lamongan
    Date examination: Feb 27, 2015

    Chief complaint :

    Pain of his body

    MOI :
    Patient complained pain of his body especially in right leg, right
    shoulder and face. Post disabit when he accompanied her girl friend
    in her house. There was 3 person did it suddenly. They let him alone
    when he couldnt do anything. He could remember the accident.
    Vomit -, headache -. Unconsiousness -.

    Airway and spine control : clear (+),


    snorring (-), gargling (-), potensial
    obstruction (-)
    Breathing : spontan, simetric (+), RR
    24x/minutes, ves/ves, rh-/-, wh-/Circulation : PR 90x/minutes, acral warm dry
    red, CRT < 2, Sp02 distal 99%, blood
    presure 95/67 mmHg
    Disability : GCS 456, LP +/+, isocor pupil
    3mm/3mm, lateralisasiExposure : temp 35

    History past illness History of social, economic :Status Generalis


    Head and neck : anemic (-), icteric (-), cyanosis (-),
    dyspneu (-) vulnus stasum
    Thorax : simetric (+), retraction (-)
    Pulmo : ves/ves, rh-/-, wh-/Cor : S1S2 single, murmur (-), gallop (-), lession Abdomen : flat, soepel, tympani (+), liver and spleen
    were not palpable, bowel sound (+), lession-, injury
    Extremities : acral warm, dry, red, lession- multiple
    vulnus appertum

    Et regio antebracii dextra :


    - Look : multiple vulnus appertum, bone
    exposure +, deformitas +, degloving +
    - Feel : pain +, pultation of distal arteri +
    99%, laceration degloving 20cm
    - Move : ROM wrist until digiti +
    Regio frontalis :
    - Look : Vulnus stasum et regio frontal dextra
    10 cm
    - Move : Minimal movement ec pain

    Clue and cue


    Male, 42 years old
    Pain of her body
    Et regio antebracii dextra :
    - Look : multiple vulnus appertum, bone exposure
    +, deformitas +, degloving +
    - Feel : pain +, pultation of distal arteri + 99%,
    laceration degloving 20cm
    - Move : ROM wrist until digiti +
    Regio frontalis :
    - Look : Vulnus stasum et regio frontal dextra 10
    cm
    - Move : Minimal movement ec pain

    Open fracture antebracii Dextra degloving


    Open fracture brain expose frontral sinitra

    CBC
    Random Blood Glucose
    Head CT Scan without contras
    Antebracii Photo

    Eritrosit : 5,27
    Diff : 8.7/1.7/37.9/47.5/4.2
    Hct : 42,6
    Hb : 15,7
    LED : 9/15
    Leukosit : 19.400
    Trombosit : 382.000
    GDA 205
    SGOT : 29
    SGPT : 51
    RDW : 12
    MCV : 80.80
    MCHC 36.9
    MPV : 6

    Open fracture ulna 1/3 distal dextra

    Ivfd Assering 1500 cc/24 h


    Inj ceftriaxon 2 gr iv
    Inj tentagram 1 amp
    Inj ranitidine 2x50 mg iv
    Inj metronidazole 3x30 mg iv
    SPALK
    c/ dr. AAO, Sp.OT Pro cito op
    c/ dr. Orizanov, Sp.An acc op prepare 1
    bag WB

    Subjective complaint
    Vital sign

    Explain to the patients family about the


    diagnosis, etiology, intervention of therapy,
    complication, and prognosis.

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