Professional Documents
Culture Documents
Post Test: Closed Fracture Right Tibia Fubula
Post Test: Closed Fracture Right Tibia Fubula
Presentator
Dzul Akbar Insani - 133307010082
PATIENT STATUS
PATIENT IDENTITY:
Name : Tn. Y
Number Of MR : 085730
Age : 33 years old
Gender : female
Religion : Buddha
ANAMNESA
Primary Survey
A : Airway clear, no airway obstruction
B : RR : 20 x / I
C : HR: 92 x / i, regular
D : GCS : 15 (E4V5M6)
E : T: 37 ºC
GENERAL STATUS
Head : Normocephali
Eyes : Pupil: Isokor (+ / +)
Sclera : Ikterik (- / -)
Conjunctiva : Anemis (- / -)
Light reflex : (+ / +)
Ear : Normal shape, secretions (-)
Nose : Normal shape, hyperemic konka (-), septal deviation (-)
Mouth : Normal shape, cyanosis (-)
Neck : Lymph nodes enlargement (-)
Thorax (Lungs)
Inspection : fusiform symmetrical chest shape
Palpation : right = left stem fremitus
Percussion : sonor
Auscultation : Vesikuler
Heart
Inspection : ictus cordis is not visible
Palpation : ictus cordis palpable
Percussion : dim, right and left heart limits cannot be assessed
Auscultation : S1S2 normal, Gallop (-), Murmur (-)
Abdomen
Inspection : symmetrical
Palpation : soepel, tenderness (-), hepatomegaly (-),
splenomegaly (-)
Percussion : timpani
Auscultation : peristalsis (+) normal impression
Extremity
Superior : warm + / +, pain -/-, edema - / -
Inferior : warm + / +, pain - / -, edema - / -
Orthopedic examination
Look
Swelling in the tibia fibula region
Feel
Pain (+)
Move
Rigidity (+), contracture (-)
Temporary Diagnosis:
closed fracture right tibia fibula
Recommendation:
- Laboratory examination (complete blood, clotting time, bleeding
time)
Laboratory examination
HEMATOLOGI
Laju Endap
3 1.4 mm/jam 0 – 20
Darah
RENAL FUNCTION
Action:
1. Supine position under general anesthesia
2. Disinfectants and drapping procedures
3. Incision and identification of fractures
4. Wash the wound and cover the wound
5. Reduction and installation of ORIF
RADIOLOGI - Post Surgery
Post operative Assessment :
Education:
1. Do not maneuver which can inhibit wound
healing and
2. Schedule a re-consultation to monitor the
results of the action.
THANK YOU