MORPORT 27 Agustus 2015
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Night Shift ReportDokter Jaga Trauma : dr. Benny
Lydia ImeldaNani Yuanita
Aji IsraMutiara Natasha
Nabila GaryudanefiGracia Fensynthia
Floria Stefani SGabriella Caroline
AdellaLamhot PurbaNadia Salima
Titus Rheihandro
28th, August 2015
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Pasien trauma: 1
Pasien non trauma:1
Hospitalized: 1
Non hospitelized: 1
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1. Tn. B (42 tahun)00-86-94-25
• Mekanisme trauma : pasien sedang mengendarai motor lalu ditabrak mobil
• Target organ luka : bahu kanan• Gejala dan Tanda : Nyeri dan luka di bahu
kanan• Pengobatan Pre Hospital : tidak ada
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PRIMARY SURVEY
• Airway : CLEAR– Look : tidak ada obstruksi– Listen : tidak ada bunyi napas tambahan
gurgling (-), snoring (-), stridor (-)– Feel : terasa udara hangat dari hidung dan mulut
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• Breathing : CLEAR– Inspeksi : memar (-); pergerakan dinding dada
simetris, RR 20 x/menit– Palpasi : krepitasi (-), emfisema subkutis (-)– Perkusi : sonor kiri=kanan– Auskultasi : bunyi napas dasar vesikuler, rh -/-, wh -/-
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• Circulation : Tidak ada tanda syok– Ekstremitas hangat– Nadi 76x/mnt, kuat angkat, isi cukup, teratur– Tekanan darah 130/90mmHg– CRT <2”,<2’’
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• Disability– GCS 15 (E4M6V5) pupil isokor, 3 mm/3 mm, ditengah
– Refleks cahaya langsung +/+ Refleks cahaya tidak langsung +/+
• Exposure Tidak ada luka lain yang mengancam nyawa
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SECONDARY SURVEY
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• A : Antibiotik• M: disangkal• P : disangkal• L : pkl 12.00• E : KLL
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History of IlnessPasien datang ke UGD RS UKI karena tertabrak mobil ± 30 SMRS. Pasien tertabrak mobil saat mengendarai motor dari arah kanan, dengan kecepatan motor kira-kira 60 km/jam dan pasien menggunakan helm. Pasien terjatuh ke arah depan dan terlempar, lengan kanan terlebih dahulu terkena aspal. Mual & muntah disangkal. Nyeri kepala disangkal, nyeri pada leher disangkal. Pasien dapat mengingat kejadian sebelum dan sesudah kecelakaan dengan baik.
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HEAD TO TOE
Kepala : normocephali, jejas (-). edema (-), laserasi (-) Mata : Pupil isokor, 3mm/3mm, di tengah, refleks
cahaya langsung +/+, Refleks cahaya tidak langsung +/+, CA -/-
Leher : tidak ada pembesaran KGB, jejas (-), nyeri tekan (-)
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Thorax :- Inspeksi : pergerakan dinding dada simetris- Palpasi : vokal fremitus simetris kanan & kiri- Perkusi : sonor kanan = kiri- Auskultasi : bunyi nafas dasar vesikuler,
Wh -/-, Rh -/-, BJ I dan II reguler, gallop (-), murmur (-)
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Abdomen :-Inspeksi : datar-Auskultasi : bising usus (+) 6 x/min-Perkusi : Timpani, nyeri ketok (-)-Palpation : supel, defense muscular (-), nyeri
tekan (-)
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Ekstremitas
Akral hangat, CRT< 2”Edema -/-
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Status Lokalis
Regio supraclavicula dextraL : tampak luka lecet dengan ukuran
5cmx5cm, perdarahan aktif (-) F : nyeri tekan (+)M: ROM terbatas
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• Regio phalangs dextra L ; 3 luka ekskoriasi ukuran Ø 0,5cm.
perdarahan aktif (-)F : nyeri tekan (-)
ROM tidak terbatas
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• Regio scapula dextra
L : terdapat multiple ekskoriasi dengan ukuran 0,5x0,5 cm, 0,5x0,5 cm, 2x2 cmperdarahan aktif (-)F : nyeri tekan (-)
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Diagnosa Kerja
Fraktur Tertutup Clavicula Dextra Non Displacement dan multiple vulnus eksoriasi
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Penanganan• Pro Rawat Inap• Diet : Biasa• IVFD : I RL/24 jam• Mm/ ketorolac 1amp• Pro ORIF (namun pasien minta rujuk sendiri
ke alternatif)• Penanganan konservatif pemasangan arm
sling.
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2. Tn. E (35 tahun)No. RM 00-06-94-24
• Keluhan utama : Nyeri pada luka di kaki kiri
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Riwayat penyakit sekarang
Pasien datang dengan keluhan luka pada kaki kiri. Luka pada kaki kiri
dirasakan pasien sejak ±3 minggu yang lalu setelah pasien terjatuh dari
motor. Pada saat kejadian, kaki kiri pasien mengenai stang gigi motor
sampai tertusuk. Setelah itu pasien membersihkan lukanya sendiri dengan
alkohol namun tidak ditutup. ± 1 minggu yang lalu luka menjadi bengkak
dan timbul nanah. Pasien sempat ke Puskesmas dan sudah diberikan
analgetik. Pasien juga mengaku 3 hari terakhir mengalami demam.
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Riwayat Penyakit Dahulu
-Pasien belum pernah mengalami hal seperti ini sebelumnya
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Tanda-tanda Vital
• Keadaan Umum : tampak sakit sedang• Kesadaran : compos mentis (GCS 15)• Tekanan Darah : 130/90 mmHg• Nadi : 82x/menit• Pernapasan : 19x/menit• Suhu 37˚C
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Kepala : NormocephaliMata : Pupil isokor 3mm/3mm, di tengah,
refleks cahaya langsung +/+, Refleks cahaya tidak langsung +/+, CA -/-, SI -/-
Telinga : NormalLeher : Tidak ditemukan pembesaran KGB
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Thorax :- Inspeksi : pergerakan dinding dada simetris- Palpasi : vokal fremitus simetris kanan & kiri- Perkusi : sonor kanan =kiri- Auskultasi : bunyi nafas dasar vesikuler,
Wh -/-, Rh -/- BJ I & II reguler, murmur (-), gallop (-)
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Abdomen :-Inspeksi : perut tampak datar, jejas (-)-Auskultasi : bising usus (+) 4 x/min-Perkusi : timpani, nyeri ketok (-)-Palpasi : supel, nyeri tekan (-)
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Ekstremitas Akral hangat, CRT < 2’’, odem -/-
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Status Lokalis Regio Cruris Sinistra• L : tampak luka menggaung dengan ukuran 5x3x2
cm, dasar luka fascia, pus (+), udem (+), jaringan sekitar luka hiperemis dan kulit pinggiran luka menghitam
• F : terasa hangat, krepitasi (-), nyeri tekan (+), nyeri sumbu (-), arteri dorsalis pedis teraba baik sama dengan kanan, kekuatan otot baik, sensibilitas berkurang.
• M : ROM tidak terbatas
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Laboratorium27/08/2015
Pemeriksaan Hasil Nilai Normal
Hemoglobin 13,6 g/dl 14-16 g/dl
Leukosit 5,0 ribu/Ul 5-10 ribu/ul
Hematokrit 40 % 40-48 %
Trombosit 362 ribu/Ul 150-400 ribu/ul
GDS 97 mg/dl <200 mg/dl
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Pemeriksaan Hasil Nilai NormalNatrium 137 136-145 mmol/L
Kalium 3,5 3,5-5,1 mmol/L
Clorida 111 99-111mmol/L
Masa Pendarahan 2 1-3 menit
Masa Pembekuan 13 10-16 menit
Masa Protombin 16 10-16 detik
SGOT 24 10-34 U/L
SGPT 32 9-43 U/L
Ureum Darah 28 15-45 mg/dL
Kreatinin Darah 0,81 0,70-0,10 mg/dL
GDS 121 <200 mg/dL
Laboratorium27/08/2015
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Diagnosa Kerja
Vulnus Laserasi Regio Cruris Sinistra + Sellulitis
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Penanganan-Pro rawat inap-IVFD : IRL/24jam-Cek Lab h2tl, mp3- foto thorax -Mm: Ceftriaxone 2x1gr (IV)
Omeprazole 2x1 (IV)Ketorolac 3x1 (IV)
-Pro debridement + Rotational Flap di ruang OK
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Terima Kasih