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    Vii. Diagnosis Diagnosis Primer

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    Winanda Denis
    The patient was diagnosed with a fractured thoracic vertebrae along with hematopneumothorax, pneumothorax, and fractured ribs from a blunt abdominal trauma. Secondary diagnoses included 10-11 week pregnancy and complications of paraplegia. Treatment plans included inline immobilization, urgent realignment, oxygen supplementation, IV fluids, and injections for pain and acid reflux. Monitoring involved patient complaints, vital signs, signs of infection, neurological status, and chest drain output.

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    Vii. Diagnosis Diagnosis Primer

    Uploaded by

    Winanda Denis
    4 views3 pages
    The patient was diagnosed with a fractured thoracic vertebrae along with hematopneumothorax, pneumothorax, and fractured ribs from a blunt abdominal trauma. Secondary diagnoses included 10-11 week pregnancy and complications of paraplegia. Treatment plans included inline immobilization, urgent realignment, oxygen supplementation, IV fluids, and injections for pain and acid reflux. Monitoring involved patient complaints, vital signs, signs of infection, neurological status, and chest drain output.

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    The patient was diagnosed with a fractured thoracic vertebrae along with hematopneumothorax, pneumothorax, and fractured ribs from a blunt abdominal trauma. Secondary diagnoses included 10-11 week pregnancy and complications of paraplegia. Treatment plans included inline immobilization, urgent realignment, oxygen supplementation, IV fluids, and injections for pain and acid reflux. Monitoring involved patient complaints, vital signs, signs of infection, neurological status, and chest drain output.

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    4 views3 pages

    Vii. Diagnosis Diagnosis Primer

    Uploaded by

    Winanda Denis
    The patient was diagnosed with a fractured thoracic vertebrae along with hematopneumothorax, pneumothorax, and fractured ribs from a blunt abdominal trauma. Secondary diagnoses included 10-11 week pregnancy and complications of paraplegia. Treatment plans included inline immobilization, urgent realignment, oxygen supplementation, IV fluids, and injections for pain and acid reflux. Monitoring involved patient complaints, vital signs, signs of infection, neurological status, and chest drain output.

    Copyright:

    © All Rights Reserved
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    Flag for inappropriate content
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    of 3

    VII.

    DIAGNOSIS
    Diagnosis primer:
    Fraktur vertebra thoracalis 8-9 AOSpine type C Frankel Grade A + Hematopneumothorax D
    + Pneumothorax S + CF costae 7-10 posterior S + CF costa 9 posterolateral S + trauma
    tumpul abdomen
    Diagnosis Sekunder:
    - GIIP1001 10/11 minggu
    Diagnosis komplikasi:
    - Paraplegia inferior

    VIII. PLANNING TERAPI


     Inline immobilization
     Urgent realignment
     O2 mask 10 lpm
     IVFD NaCl 0,9 % 1500 ml/24 jam
     Injeksi metamizole 1 g/8 jam IV
     Injeksi Ranitidine 50 mg/12 jam IV

    IX. MONITORING
     Keluhan dan klinis
     Vital signs
     Status neurologis

    1
    X.Kondisi saat ini (20/11/2018)
    XI Status Generalis (20/11/2018)
    Keadaan umum Cukup
    Vital sign
    Tekanan darah 120/80 mmHg
    Nadi 96x/menit
    RR 20 x/ menit
    Temp 36,6 0 C
    Kepala/Leher Anemia – icterus – cyanosis – dyspnea -, edema oculi dextra
    Simetris, retraksi- P vesikuler menurun/vesikuler menurun C
    Thorax S1S2 tunggal
    Abdomen Supel, BU Normal
    Ekstremitas AHKM, CRT <2” edema-
    Kepala/Leher Anemia – icterus – cyanosis – dyspnea -

    XII.Status Neurologis (20/11/2018)


    GCS : E4VXM6
    Meningeal sign/KK :-
    Nervus Cranialis :
    I : tidak dievaluasi
    II-III : pupil bulat isokor 3mm/3mm, refleks cahaya +/+
    III-IV-VI : dalam batas normal
    V motorik : dalam batas normal, refleks kornea +/+
    V sensorik : dalam batas normal
    VII : dalam batas normal
    VIII : tidak dievaluasi
    IX, X : tidak dievaluasi
    XI : dalam batas normal
    XII : dalam batas normal
    Status Motorik 5|5 0|0
    Sistem Sensorik : dalam batas normal

    Refleks fisiologis : BPR +2 | +2 KPR +1 | +1

    TPR +2 | +2 APR +1 | +1

    Refleks patologis : Babs - | - Opp - | - Trom - | -

    2
    Chad - | - Hoff - | -
    Cerebellum : tidak dievaluasi
    Collumna vertebralis : tidak dievaluasi
    Sistem saraf otonom : dalam batas normal

    Diagnosis primer:
    Fraktur vertebra thoracalis 8-9 AOSpine type C Frankel Grade A + Hematopneumothorax D
    + Pneumothorax S post pemasangan drain + CF costae 7-10 posterior S + CF costa 9
    posterolateral S + trauma tumpul abdomen + post realigment + inline immobilization

    Diagnosis Sekunder:
    - GIIP1001 10/11 minggu

    Diagnosis komplikasi:
    - Paraplegia inferior

    Planning
     O2 mask 10 lpm
     IVFD NaCl 0,9 % 1500 ml/24 jam
     Injeksi metamizole 1 g/8 jam
     Injeksi Ranitidine 50 mg/12 jam

    Monitoring;
    • Keluhan dan klinis
    • Vital signs
    • Tanda infeksi
    • Status neurologis
    • Produksi chest drain

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