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  • Tugas Clerk Bedah

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    Kelompok B is identifying themselves. The document is a medical record containing: 1) Identitas details of a 60 year old male patient named Tn. Supiran who was admitted on December 25th 2016 at 7am following a motorcycle accident where he fell and injured his left leg. 2) Anamnesis revealing pain in his left leg post old fracture, falling to the left side, dizziness but no vomiting or seizures. 3) Physical examination findings including vital signs, head/neck/chest/abdomen examinations and localized tenderness and deformity to the left leg. 4) Laboratory tests showing abnormalities including elevated white blood cell count and low hemoglobin.

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    Kelompok B is identifying themselves. The document is a medical record containing: 1) Identitas details of a 60 year old male patient named Tn. Supiran who was admitted on December 25th 2016 at 7am following a motorcycle accident where he fell and injured his left leg. 2) Anamnesis revealing pain in his left leg post old fracture, falling to the left side, dizziness but no vomiting or seizures. 3) Physical examination findings including vital signs, head/neck/chest/abdomen examinations and localized tenderness and deformity to the left leg. 4) Laboratory tests showing abnormalities including elevated white blood cell count and low hemoglobin.

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    6 views9 pages

    Tugas Clerk Bedah

    Uploaded by

    LollyCheve
    Kelompok B is identifying themselves. The document is a medical record containing: 1) Identitas details of a 60 year old male patient named Tn. Supiran who was admitted on December 25th 2016 at 7am following a motorcycle accident where he fell and injured his left leg. 2) Anamnesis revealing pain in his left leg post old fracture, falling to the left side, dizziness but no vomiting or seizures. 3) Physical examination findings including vital signs, head/neck/chest/abdomen examinations and localized tenderness and deformity to the left leg. 4) Laboratory tests showing abnormalities including elevated white blood cell count and low hemoglobin.

    Copyright:

    © All Rights Reserved
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    of 9

    Kelompok B

    Adzomi riski wardana


    Arieska dara permatasari
    Deka permadi trio P
    Heny purwanti
    Reny fitriani
    Pitria khairunnisa
    I. identitas
    Nomor rekam medik : 16373513
    Tanggal masuk 25 desember 2016 jam 07:00
    Nama : Tn. Supiran
    Umur :60th
    Jenis kelamin : laki-laki
    Alamat : grogot
    II. anamnesis
    • KU: nyeri pada kaki post KLL, tabrak sepeda
    pancal dengan motor.
    • Rps : posisi jatuh miring kekiri (+), mual (-),
    muntah (-), kejang (-), pusing (+).
    • Rpd : -
    III. Pemeriksaan fisik
    • Pemeriksaan fisik :
    - Vital sign: TD: 130/70 mmHg, RR:20x/menit, HR:
    98x/menit.
    - Kepala : a-/i-/c-/d-
    - Leher : pembesaran kgb (-)
    - Thorax : a. pulmonal : vesikular +/+, rhonki -/-,
    whezzing -/-
    b. Kardio : s1,s2 tunggal
    - Abdomen : Bu + N, flat +, susp +
    - Ext atas bawah: buat deka ???????
    Status lokalis
    • Regio orbita sinistra ekskoriasi (+) nyeri (+)
    • Regio frontalis sinistra ekskoriasi (+) nyeri (+)
    • Regio cruris look: edem (+), feel: nyeri (+)
    deformitas, movement : rom terbatas
    IV. Pemeriksaan penunjang
    • Radiologi:
    • Laborat : Darah rutin:
    Leukosit: 14,09 3,80-10,60
    Eritrosit : 3,37 4,40-6,00
    HB : 7,1 13,2-17,3
    hCT : 25,1 40,0-52,0
    MCV: 74,5 80,0-100,0
    Mch : 21,1 26,0-34,0
    Mchc : 28,3 32,0-36,0
    Trombosit : 388.000 150000-400000
    Rdw-sd: 46,8 37-54
    Rdw-cv : 18,1 11,0-15,6
    Mpv : 9,9
    P-lcr : 24,7
    Pct : 0,39
    V. resume
    VI. Diagnosa
    • Fraktur cruris sinistra 1/3 medial close fracture
    • S. dislokasi genue dextra
    • anemia
    VII. penatalaksanaan
    • Medikamentosa :
    - Inj. ketorolak 30 mg ampul
    - Inj. Ranitidin 2x1 ampul
    - Ivfd N5 0,9% 500cc/24jam
    - inj. Dipenhydramin 2x1 ampul
    • Non – medikamentosa
    - Wound talet
    - Spalk cruris sinistra, spalk genue dextra (imobilisasi
    sementara)
    - Transfusi PRC 1half/jam s/d hb lebih samadengan 10

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