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    Selama CC Berlangsung: No Cell Phone No Camera

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    RadenSiwi Bagus Hadhiningrat
    The document summarizes the visit of a 73-year-old female patient named Mrs. S to the emergency department. She fell and injured her right thigh. Upon examination, she was found to have a spiral fracture of the distal right femur. Her treatment plan included immobilization, consultation with internal medicine, and elective surgery to place a locking plate for the femur fracture. The document also provides timelines of her care and assessments.

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    Selama CC Berlangsung: No Cell Phone No Camera

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    RadenSiwi Bagus Hadhiningrat
    12 views21 pages
    The document summarizes the visit of a 73-year-old female patient named Mrs. S to the emergency department. She fell and injured her right thigh. Upon examination, she was found to have a spiral fracture of the distal right femur. Her treatment plan included immobilization, consultation with internal medicine, and elective surgery to place a locking plate for the femur fracture. The document also provides timelines of her care and assessments.

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    DNY 8-5-20 Jam 21.30(10)

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    The document summarizes the visit of a 73-year-old female patient named Mrs. S to the emergency department. She fell and injured her right thigh. Upon examination, she was found to have a spiral fracture of the distal right femur. Her treatment plan included immobilization, consultation with internal medicine, and elective surgery to place a locking plate for the femur fracture. The document also provides timelines of her care and assessments.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    12 views21 pages

    Selama CC Berlangsung: No Cell Phone No Camera

    Uploaded by

    RadenSiwi Bagus Hadhiningrat
    The document summarizes the visit of a 73-year-old female patient named Mrs. S to the emergency department. She fell and injured her right thigh. Upon examination, she was found to have a spiral fracture of the distal right femur. Her treatment plan included immobilization, consultation with internal medicine, and elective surgery to place a locking plate for the femur fracture. The document also provides timelines of her care and assessments.

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    SELAMA CC BERLANGSUNG

    NO CELL PHONE NO CAMERA

    NO GADGET NO FOOD & DRINK


    Visi Program Studi
    Ilmu Bedah
    • Menjadi Program studi dokter spesialis ilmu
    bedah bereputasi International,
    BEDA menghasilkan lulusan profesional, unggul di
    bidang penanganan multiple trauma dan
    H kanker lini pertama
    Misi Program Studi Ilmu Bedah

    Menyelenggarakan pendidikan Berkualitas, berdasarkan


    kurikulum KIBI dengan memberikan keunggulan pada
    penanganan multiple trauma dan kanker lini pertama

    BEDA Mengembangkan Penelitian dan pengabdian di bidang Ilmu


    Bedah khususnya penanganan multiple trauma dan kanker
    lini pertama
    H
    Menyelenggarakan tata kelola program studi Berbasis Good
    University Governance, menuju institusi bereputasi
    Internasional
    LAPORAN JAGA
    Hari jum`at, 8 Mei 2020

    Chief : dr. Donny Artya Kesuma


    Jaga 3 : dr. Aulia (ATH), dr. Kurniadi (DDI)
    Jaga IGD : dr. Alia (ADE), dr. Siwi (SIW)
    dr. Taufik (THD), dr. Ardi
    (NOV)
    Jaga IPI / Bangsal : dr. Adly (DLY)
    REKAP KUNJUNGAN IGD

    Rawat Inap
    No Identitas Diagnosa Tindakan
    1. Mrs. S CF of 1/3 Distal Right Shaft IVFD. RL 20 dpm
    73 yo Femur Spiral Type Ketorolac inj 30 mg/8hr
    01503622 Hypertension grade II Routine Blood Examination
    Geriatric Chest X-ray
    Porotic Bone Right Femur X-ray
    Pelvic X-ray

    Orthopedic
    Immobilization with skin traction
    ORIF Femur Elective (Locking
    Plate)
    Consult to Internal Medicine
    Department Sub Geriatric
    Rawat Jalan
    No Identitas Diagnosis Keterangan
    1 Ny. S Contusio musculorum R. Asam Mefenamat 3 x 500mg
    75 th Femur (S)
    01493886
    2 Tn. S Dx Emergency : Retensi Rawat Jalan
    61 th Urine Pulang bawa DC
    00942649 Dx Primer : BPH Work Up Dx dari Poli
    Dx Lain : -
    Dx Komplikasi : -

    Pavilliun

    No Identitas Diagnosis Keterangan


    - - - -
    Konsulan
    No Identitas Diagnosis Tindakan

    - - - -

    Meninggal
    No Identitas Diagnosis Keterangan

    APS
    No Identitas Diagnosis Keterangan
    - - - -
    Name : Mrs. S
    Age : 73 y.o
    Med. Record: 01503622
    Payment : National Health Insurance
    Chief Complaint :
    Pain on right thigh

    Present Illness :
    Ten hours prior to admission while the patient was walking on her
    house, suddenly she was slipped and fell down. She fell down with her
    right thigh hit the corner of the floor. Unconsiousness (-), vomit (-),
    convulsions (-). After the incident, the patient complained about pain
    on her right thigh and gotten worse by movement. By her family, she
    was taken to RSDM.

    Past Illness :
    History of HT (+)
    History of DM (-)
    History of ambulation : she can walk without walking aids
    Covid 19 screening:
    Flu like symtoms (-)
    History of fever and malaise (-)
    Sore throat (-)
    History of traveling (-)
    Contact with covid patients (-)
    Vesicular breath sound (+/ +)
    Body tempt 36.3 °C

    EWS Score : 1
    Primary Survey

    A : Clear
    B : I : chest expansion right = left, RR: 20 x/min
    P : crepitation (-/-)
    P : Sonor/Sonor
    A : vesicular breath sound (+/+), additional sound (-/-)
    C : HR : 92 x/mnt BP : 180/90 mmHg
    D : GCS E4V5M6, equal width pupil (3 mm/3 mm), light
    reflexes (+/+), lateralization (-)
    E : T : 36,3 °C
    Secondary Survey
    Head : no abnormality
    Eyes : no abnormality
    Nose : no abnormality
    Mouth : no abnormality

    Ear : no abnormality
    Neck : no abnormality
    Chest : no abnormality
    Abdomen : no abnormality
    Extremities : Look at localized status
    Localized Status
    Right Thigh Region
    L : Skin Intact (+), swelling (+), deformity
    shortening (+), external rotation (+)
    F : NVD (-), Leg length discrepancy 2cm
    M: ROM Hip and knee limited due to pain
    LLD D S
    Apparent Length 84 86
    True Length 76 78
    Anatomical length 41 43
    1st Assesment :
    CF of Right Femur (ICD X S72.3)
    Hypertension grade II
    Geriatric

    1st Plan :
    IVFD. RL 20 dpm
    Ketorolac inj 30 mg/8hr
    Routine Blood Examination
    Chest X-ray
    Right Femur X-ray
    Pelvic X-ray
    AO Classification
    2nd Assesment :
    CF of 1/3 Distal Right Shaft Femur Spiral Type AO 32-A1 (ICD X
    S72.302A)
    Hypertension grade II (ICD X I16.0)
    Geriatric (ICD X R41.81)
    Porotic Bone (ICD X M81.0)

    2nd Plan :
    Orthopedic
    Immobilization with skin traction
    ORIF Femur Elective (Locking Plate)
    Consult to Internal Medicine Department Sub Geriatric
    Arrival Time 01.30
    Triage Time 01.35
    Surgery Dept. Time 01.45
    Laboratorium Time 01.50 - 03.00
    Radiology Time 02.00 – 02.45
    Diagnosa Time 03.15
    Inward 04.00
    TERIMAKASIH

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