Status Pemeriksaan Pasien Fraktur
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Transcript of Status Pemeriksaan Pasien Fraktur
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8/12/2019 Status Pemeriksaan Pasien Fraktur
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CLOSED FRACTURE CRURIS DEKSTRA 1/3 PROXIMAL
STATUS PEMERIKSAAN PASIEN
DEPARTEMEN BEDAH
I. Identitas Pasien
Nama : Tn. X
Umur : 21 Tahun
Jn!" K#am!n : La$!%#a$!
A#ama& : %
A'ama : %
S&a&u" : %
P$r(aan : %
Tan''a# ma"u$ RS : 1) A'u"&u" 2*13
Ruan'an : %
N+ MR : %
II. Anamnesis
Anamn"!" ,!#a$u$an "-ara au&+anamn"!" a,a &an''a# 1) A'u"&u" 2*13 u$u# *0.**
I. ,! RSAL Dr M!n&+har(+.
Keluhan Utama
Pa"!n ,a&an' a"-a KLL ,n'an $#uhan mmar a,a $a#a a'!an #a$an' ,!"r&a!
!n'"an "#ama 0 mn!&. Pn,r!&a mn'#uh ""a$ naa" ,an n4r! a,a ,a,a $anan. S#a!n
!&u ,!,aa&$an (u'a ,5+rm!&a" a,a "n,! an''u# $anan 4an' "an'a& "a$!& $a#au "n,!
an''u# ,!'ra$$an.
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Anamnesa Lengkap
Pa"!n #a$!%#a$! 21 &ahun ,a&an' ,n'an $-#a$aan #a#u #!n&a" "a&u (am 4an' #a#u.
P!n'"an "#ama 0 mn!& &!,a$ mun&ah%mun&ah n,r!&a #ua aa 4an' aru &r(a,! a,a
mmar a,a $a#a a'!an #a$an' r,arahan a,a mu#u& h!,un' ,an !n'a &!,a$ a,a.
Pn,r!&a &ama$ ""a$ na5a" ,an &ra"a n4r! a,a ,a,a $anan. Dan n,r!&a (u'a
mn'#uh$an $#a!nan n&u$ a,a "n,! an''u# $anan 4an' "an'a& "a$!& $a#au "n,!
an''u# ,!'ra$$an.
III. Pemeiksaan !isik
A. Keadaan Umum
K"an "a$!& : Tama$ "a$!& ra&
K"a,aran : C+m+" Mn&!"
S&a&u" '!6! : : 0* $'
T : 17* -m
IMT : 1803 $'/m29'!6! -u$u
Cara rar!n' ,an m+!#!&a" :Tidak akti"
S!$a : K++ra&!5
B. Tanda #ital
T$anan ,arah: 8*/)* mm;'
Na,! : 12*
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CLOSED FRACTURE CRURIS DEKSTRA 1/3 PROXIMAL
$. Status genealis
Kulit
arna : Sa=+ ma&an' u-a& 9% "!an+"!" 9% !$&r!$ 9% ruam 9% 55#+r"n"! 9%
Tur'+r : a!$
Suhu : Traa han'a&
L"! : T!,a$ &r,aa& #"!
Kepala
n&u$ : N+rm+-ha#! &!,a$ &r,aa& ,5+rm!&a"
Ramu& : Ramu& r=arna h!&am &a# #uru" ,!"&r!u"! mra&a &!,a$ mu,ah ,!-au&
%a&ah
In"$"! : S!m&r!" u-a& 9%' "!an+"!" 9% ,an !$&r!$ 9% +,m 9%
Mata
o K,u,u$n $,ua +#a ma&a "!m&r!"
o K#+a$ ma&a: P&+"!" 9% E,ma 9%
o K+n(un'&!>a u-a&()(
o S$#ra I$&r!$ %/%
o Pu!#: I"+$+r &! ra&a ,!am&r 0 mm r5#< -aha4a #an'"un' ?/? r5#< -aha4a
&!,a$ #an'"un' ?/?
o E$"+5&ha#mu" 9% ,an N4"&a'mu" 9%
o @ra$an +#a ma&a a!$
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Telinga
N+rm+&!a n4r! &ar!$ %/% n4r! &$an &ra'u" %/% ma&u" a$u"&!$u" $"&rnu" #aan' ?/?
"rumn %/% "$r& %/% mmran &!man! !n&a$ ?/? r,arahan 9%/%
Hidung
n&u$ n+rma# &!,a$ &r,aa& ,5+rm!&a" ,>!a"! "&um 9% "$r& %/% mu$+"a
h!rm!" %/% r,arahan -a>um na"! %/%
Bi*i
n&u$ n+rma# "!m&r!" &!,a$ &ama$ $r!n' &!,a$ &ama$ "!an+"!" mu$+"a !!r a&a"
,an a=ah &!,a$ h!rm!".
Mulut
Ora# h4'!n a!$ $ar!" %/% '!'! +m+n' %/% #!,ah &!,a$ &ama$ $+&+r #an'!&%#an'!&
n+rma#
Tengg++kan
T+n"!# T1%T1 &!,a$ h!rm!" $r!&a &!,a$ m#ar ,&r!&u" %/% #!,ah n+rma# u>u#a
,!&n'ah ar-u" 5ar!n' "!m&r!" mu$+"a 5ar!n' &!,a$ h!rm!" ,an &!,a$ 'ranu#r.
Lehe
Tra$a &raa ,!&n'ah JP 0?2 -m;2O $#n(ar '&ah n!n' &!,a$ &raa mm"ar
&!r+!, &!,a$ &raa mm"ar.
Th+aks
Paru-paru
In"$"! : N+rm-h"& ,!n,!n' ,a,a "!m&r!" a!$ "&a&!" ,an ,!nam!"
&! rna5a"an &h+ra-a#% a,+m!na# r&ra$"! "#a !'a 9%.
Pa#a"! : @ra$an ,!n,!n' ,a,a "!m&r!" >+-a# 5rm!&u" "!m&r!" $anan ,an $!r!
Pr$u"! : S+n+r ,!$,ua #aan' aru
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Au"$u#&a"! : "!$u#r ?/? rh %/% =h %/%
Jantung
In"$"! : T!,a$ &ama$ u#"a"! !$&u" -+r,!"
Pa#a"! : Traa !$&u" -+r,!" a,a ICS 1 -m m,!a# ,ar! #!na m!,$#a>!$u#a $!r!
Pr$u"! : a&a" (an&un' $anan : ICS III % #!na "&rna#!" ,
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K!r! : S!m&r!" "!an+"!" 9% ,ma 9% a$ra# han'a& ,5+rm!&a" 9% $r!&a"! 9% n4r!
9% a&r+5! +&+& 9% "n,! &!,a$ a,a $#a!nan. 'ra$an a$&!5.
Ekstemitas *a,ah
Kanan : L!ha& "&a&u" #+$a#!"
K!r! : S!m&r!" "!an+"!" 9% ,ma()( a$ra# han'a& ,5+rm!&a" 9% $r!&a"! 9% n4r!
9% a&r+5! +&+& 9% "n,! &!,a$ a,a $#a!nan 'ra$an a$&!5
D. Status L+kalis - Regi+ $uis Deksta '
L++$
S$!n : Lu$a #-& 9? =arna mrah $!ruan ,!"$!&ar #u$a #u$a &ru$a 9%
Sha : O,m 9? ,5+rm!&a" 9?
P+"!&!+n : Ma#+"!"! 9?
F#
S$!n : N4r! &$an 9? a$ra# han'a& 9?
S+5& T!""u: O,m 9? A&r+5! +&+& 9%
+n : Kr!&a"! 9?
Pu#" : A. ,+r"a#!" ,!" &raa #mah
M+>
A$&!5 : Tr,aa& ma&a"an 'ra$ $arna n4r!
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Pa"!5 : Tr,aa& ma&a"an 'ra$ $arna n4r!
P+=r : Su#!& ,!n!#a! $arna n4r!
I#. Pemeiksaan Penun&ang
. Pemeiksaan la*+at+ium tanggal /0 Agustus 1/2
Paamete Nilai Nilai Ru&ukan Satuan
Daah Lengkap
Lu$+"!& .3// 0 B 1* 1*3/uL
Er!&r+"!& )8 )0 % 00 1*7/mm3
;m+'#+!n 1 1) B 17 '/,L
;ma&+$r!& 38 3 B )7
Tr+m+"!& 28.*** 10* B )** 1*3/mm3
Kimia Daah
S@OT 3) 30 U/L
S@PT )* )1 U/L
Urum 22 1 B )3 m'/,#
Cra&!n!n * *7 B 1 m'/,#
Hemat+l+gi
#,!n' &!m 2G**H 1 B 7 Mn!&
C#+&h!n' &!m 11G**H 1* B 17 Mn!&
4ula Daah
@#u$+"a S=a$&u 1* 2** m'
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1. Pemeiksaan Radi+l+gis
F+&+ r+n&'n -rur!" ,$"&ra &an''a# *) A'u"&u" 2*13
Deskipsi 5
% Jn!" 5+&+ : AP%La&ra#
% S'! $+n5!'ura"!n4a : Fra$&ur $+m#!& -+mm!nu&!5 +" &!!a ,an 5!u#a ,$"&ra 1/3
r+
% S'! $,u,u$ann4a : Fra$&ur a,a +" &!!a ,an 5!u#a ,$"&ra 1/3 r+
,!"#a-, 9?
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% D!"#+$a"! "n,! : D!"#+$a"! "n,! 9%
Kesan
C#+", Fra-&ur +" &!!a ,an 5!u#a ,$"&ra 1/3 r+
F+&+ R+n&'n &h+ra< PA
Deskipsi 5
% S!nu" ,!a5ra'ma #ura ,an -+r a!$ &!,a$ &ama$ 5u"!
% A+r&a : a!$ &a$ m#ar
% Pu#m+ : C+ra$an r+n-h+>a"-u#r ,an h!#u" a!$
Ta$ &ama$!n5!#&ra& / $a>!&a" a&au #"! a&+#+'!" #a!n
% Tu#an'%&u#an' ,an "+5& &!""u a!$
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Kesan 5 C+r ,an u#m+ &a$ &ama$ $#a!nan
#. Resume
an!&a 2* &ahun ,a&an' $ Un!& @a=a& Darura& 9U@D RSAL Dr M!n&+har,(+ ,n'an
$#uhan n4r! a,a &un'$a! a=ah "#ah $anan a$!a& $-#a$aan #a#u #!n&a" "(a$ 10
mn!& SMRS. Pa"!n mn'a#am! $-#a$aan "=a$&u mn'n,ara! m+&+r a,a =a$&u !&u
a"!n r&ara$an ,n'an m+!# ,ar! arah 4an' r#a=anan 4an' mn'a$!a&$an a"!n
&r(a&uh $ arah $anan "h!n''a &un'$a! $anan &r&!ma m+&+r a"!n. S"aa& "ah (a&uh
a"!n ,a#am $a,aan "a,ar ",!$!& u"!n' &!,a$ mn'a#am! mua# ,an mun&ah. Pa"!n
mn'#uh &!,a$ !"a mn''ra$$an $a$! $anann4a $arna n4r! ,an &!,a$ !"a r(a#an.
Tama$ #u$a #-& a,a &un'$a! a=ah $anan $a#a &!,a$ &rn&ur &!,a$ $#uar ,arah ,ar!
h!,un' mu#u& !n'a &!,a$ ""a$ na5a" ,an an''+&a &uuh 4an' #a!n ma"!h ,aa& ,!'ra$an.
Pa,a mr!$"aan 5!"!$ "&a&u" #+$a#!" ,arah -rur!" ,$"&ra ,!,aa&$an #u$a #-& =arna
mrah $!ruan ,!"$!&ar #u$a +,m 9? ,5+rm!&a" 9? ma#+"!"! 9? n4r! &$an 9?
$r!&a"! 9? a. ,+r"a#!" ,!" &raa #mah &r,aa& ma&a"an 'ra$ a$&!5 ,an a"!5
$arna n4r!. Pa,a mr!$"aan ra,!+#+'!" &ama$ 5ra$&ur +" &!!a ,an 5!u#a ,$"&ra 1/3
r+
#I. Diagn+sa Ke&a
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C#+", Fra-&ur Crur!" D$"&ra 1/3 Pr+
#II.Diagn+sa Banding
%
#III.Penatalaksanaan
M,!$amn&+"a
IFD RL 2* &&"/m
An&! &&anu" TT
C5&r!a$"+n 2 < 1
K&+r+#a- 3 < 1 am
N+n M,!$amn&+"a
Pra!$an $a,aan umum ,an r"!aan +ra"!
Ora&!5 : ORIF #a& "-r=
I6. P+gn+sis
a. A, >!&am : a, +nam
. A, 5un'"!+nam : ,u!a a, +nam
-. A, "ana&!+nam : ,u!a a, +nam
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