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  • Laporan Jaga P1: Minggu Malam, 28 Februari 2021

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    1. The night shift report on February 28, 2021 documents an orthopedic patient named Sumantono with open fractures of the proximal, middle, and distal phalanges of the right toe and the head of the middle phalanx of the third right toe. 2. The planned treatment is debridement, repair, exploration, and insertion of K-wires. 3. The patient's airway is patent, breathing is spontaneous without gurgling or snoring while wearing a cervical collar, and circulation shows a heart rate of 62 beats per minute and blood pressure of 106/65 mmHg.

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    Presentasi P1-1

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    1. The night shift report on February 28, 2021 documents an orthopedic patient named Sumantono with open fractures of the proximal, middle, and distal phalanges of the right toe and the head of the middle phalanx of the third right toe. 2. The planned treatment is debridement, repair, exploration, and insertion of K-wires. 3. The patient's airway is patent, breathing is spontaneous without gurgling or snoring while wearing a cervical collar, and circulation shows a heart rate of 62 beats per minute and blood pressure of 106/65 mmHg.

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    60 views16 pages

    Laporan Jaga P1: Minggu Malam, 28 Februari 2021

    Uploaded by

    Dendy
    1. The night shift report on February 28, 2021 documents an orthopedic patient named Sumantono with open fractures of the proximal, middle, and distal phalanges of the right toe and the head of the middle phalanx of the third right toe. 2. The planned treatment is debridement, repair, exploration, and insertion of K-wires. 3. The patient's airway is patent, breathing is spontaneous without gurgling or snoring while wearing a cervical collar, and circulation shows a heart rate of 62 beats per minute and blood pressure of 106/65 mmHg.

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    of 16

    Laporan Jaga P1

    Minggu Malam, 28 Februari 2021


    TEAM JAGA
    DIS-ARA/PRI/IGO-HAF/ESA/AND/NIA

    Konsulen Jaga IGD Malam : dr. Rudy Vitraludyono, Sp.An


    P1 Nihil
    identity Sumantono/L/40th/11503757/P2
    Entry Diagnosis OF proximal, middle, and distal phalanx R toe + OF head middle
    phalanx R 3rd toe
    Rencana Tindakan Debridement + repair + explore + k wire insertion
    Management Airway: Airway paten,  gurgling (-), snoring (-), terpasang cervicalis collar neck
    Breathing : Nafas spontan, pengembangan dada kanan = kiri, takipneu (-)
    Circulation : AHKM, CRT<2 detik, a.radialis teraba kuat, reguler
    Dissability :Alert
    Exposure : Edema (-), Jejas (+) kaki kiri

    B1: airway paten, napas spontan, SpO2 98% on RA 10 lpm, RR 18-20x/mnt,


    vesikuler +/+, rhonki (-/-) wh(-/-)
    B2: AHKM, CRT <2dtk, Nadi 62x/min, TD 106/65 (76) mmHg, S1S2 tunggal,
    reguler, murmur (-) gallop (-)
    B3: GCS 456,
    B4: BAK spontan
    B5: BU(+) N, distended(-), soefl (+)
    B6: Edema (-), cyanosis (-), jejas (+) r. pedis sinistra
    Entry P2 06 Februari 2021, pukul 04.00
    department involved Orthopedi

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