Duty Report

Wednesday, May 8th 2013

Consultants on duty :
Dr. Daan Khambri, SpB K.Onk, M.Kes
Dr. Roni Eka Syahputra, SpOT (K)
Dr. Syaiful Saanin, Sp.BS
Dr. Doddy Efmansyah, SpB, SpU
Residents on duty :
Hafni, ridwan, didi, icuk, irsyad, irsal, vandra

Total Patients
Patients went to operating theatre
Hospitalized Patients
Control to polyclinic
Refused to treated
Ward Report :
TC
:
HCU
:
CAA
:
CP
:
CW
:
Lb
:

25
8
23
30
19
2

patients
patients
patients
patients
patients
patients

:
:
:
:
:

2 patients
1 patient
- patient
1 patient
- patient

1st

patient

A male patient, 81 years old was

admitted to E.R with :
Chief complaint :
Pain at the left hip since 7 days before
admission

Present illness history

- Pain at the left hip since 7 days
before admission
- Patient was walking at home,
suddenly slipped down on the floor
on his left hip
- Patient still conscious after accident
- No trauma at the other part

Physical Examination
- GA : Moderately Illness
- Consciousness
: GCS 15
- Blood pressure : 140/90 mmHg
- Heart Rate : 88 x/minute
- Respiratory Rate : 20 x/minute
- Temp. : 37 C
Eyes : Conjunctive was not anemic
Thorax and abdomen were normal
5

Locally State
Left hip Region
Look : Wound (-), swelling (-), deformity
(+) abduction and external rotation,
discrepancy (+)
NVD :
Motoric and sensoric were good
Pulsation of dorsalis pedis artery (+)
Capillary refill < 2

Working Diagnose :
Closed fracture of the left proximal
femur
Laboratorium
Hb : 13,4 gr/dl

X-ray

Diagnose:
Close fracture of the left femoral neck
For this patient we perfomed
Skin traction
Planning
ORIF

Condition patient this morning

Patient is in the ward
NVD is good
Traction is good

THANK YOU