Intraoparative

Mentor: dr. Samuel Maruanaya, Sp.OT

PATIENT IDENTITY
NAME : Tn. A. Kadir Amahoru
AGE : 46 Years Old
GENDER : Male
ADRESS : Liang
ARRIVAL DATE : February 16,2024.
ARRIVAL TIME : 22:00 WIT
RELIGION : Islam
MARITAL STATUS : Married
ANAMNESIS
▪ Main complaint : wound on left leg

▪ Anamnesis (Aloanamnesis + Autoanamnesis)

The patient came to the emergency room at Latumeten Hospital with complaints of a rotting wound on his left leg. On

February 28, the patient had a single accident while riding a motorbike and suffered lacerations to his left leg. The

patient was then taken to Piru Hospital and referred to Bhakti Rahayu Hospital. The patient underwent surgery on

February 29 and was discharged from the hospital on March 6, but according to the patient while at Bhakti Rahayu

Hospital the patient's wound was not treated properly and after leaving the hospital the stitches opened and the

wound enlarged. After leaving the hospital, the wound was treated by a nurse.
ANAMNESIS

▪A :

▪ M (Medication) : Cefixime, metronidazole

▪ P (Past illness) :-

▪L :

▪E :

▪ Family history :-
PHYSICAL EXAMINATION

• BP : 100/60 mmHg

• HR : 89x/minute

• RR : 24x/minute

•T : 36,4 C

• SpO2 : 99% RA
 PHYSICAL EXAMINATION
Head : Normochepal, CA (+/+), SI (-/-)

Neck : No enlarged lymph nodes

▪Thorax ▪Abdomen

I : Symmetrical, scar (-) I : Flat, scar (-)

P : Tenderness (-) A : Bowel sounds (+)

P : Sonor in pulmo, dim in the heart P : Tenderness pain (-)

A : Vesicular (+/+), wheezing (-/-), ronchi (-/-), P : Tympani

BJ I/II regular, Gallop (-), Murmur (-)

PHYSICAL EXAMINATION

▪ Genitalia : Not checked

▪ Extremities : look local state

 Local State

Left Cruris Region

Look : looks like a wound covered in gauze, blood (+)
Feel : Tenderness pain (+)
Move : Active ROM, Unlimited
X-Ray
During-Operative Post-Operative
LAB EXAMINATION
TYPE NORMAL RANGE 16 March 2024

Hemoglobin 12.0-17.0 11.1

Red Blood Cell 4.3-5.6 4.43

White Blood Cell 4.0-10.0 7.4

Hematocrit 40-48 34.6

MCV 80-100 78.1

MCH 28.0-32.0 25.1

MCHC 31.0-35.0 32.1

PLT 150-440 805

Diagnosis

Degloving soft tissue injury post debridement +

secondary infection
Therapy

• IVFD RL 20 tpm
• Inj ketorolac 1 amp/12 jam iv
• Inj ceftriaxone 1gr/12 jam iv
Planning

Pro debridement
 POD
Maret, 18 2024 Maret, 19 2024 (H+1)

S: S:
Patient feel pain in the left leg Patient feel pain in the left leg

O: O:
BP : 120/70 mmHg BP : 120/80 mmHg
HR: 81 x/mnt HR: 75 x/mnt
Temperature : 36,5° C Temperature : 36,5° C
RR : 20 x/mnt RR : 20 x/mnt
SpO2 : 99% room air SpO2 : 99% room air

Local state : Regio Suralis Sinistra Local state : Regio Suralis Sinistra
Look : Wound covered with gauze, blood (+) Look : Wound covered with gauze, blood (+)
Feel : pain tenderness (+), pain (+) Feel : pain tenderness (+), pain (+)
Move : Active ROM, unlimited Move : Active ROM, unlimited

A: A:
Degloving soft tissue injury post debridement + secondary infection Post debridement H+1 a.i degloving soft tissue injury
P: P:
IVFD NaCl 0,9 % 20 tpm Pro. debridement IVFD RL 20 tpm pro wound care
Inj. Ketorolac 30 mg/8 jam/IV
Inj. ceftriaxone 1gr/12 jam/IV
 POD
Maret, 20 2024 (H+2) Maret, 21 2024 (H+3)

S: S:
Patient feel pain in the left leg Patient feel pain in the left leg

O: O:
BP : 110/70 mmHg BP : 110/70 mmHg
HR: 76 x/mnt HR: 77 x/mnt
Temperature : 36,7° C Temperature : 36,6° C
RR : 20 x/mnt RR : 20 x/mnt
SpO2 : 99% room air SpO2 : 97% room air

Local state : Regio Suralis Sinistra Local state : Regio Suralis Sinistra
Look : Wound covered with gauze, blood (+) Look : Wound covered with gauze, blood (+)
Feel : pain tenderness (+), pain (+) Feel : pain tenderness (+), pain (+)
Move : Active ROM, unlimited Move : Active ROM, unlimited

A: A:
Post debridement H+2 a.i degloving soft tissue injury Post debridement H+3 a.i degloving soft tissue injury
P: P:
IVFD RL 20 tpm pro wound care Inj. IVFD RL 20 tpm pro wound care
Ketorolac 30 mg/8 jam/IV Inj. Ketorolac 30 mg/8 jam/IV
Inj. ceftriaxone 1gr/12 jam/IV Inj. ceftriaxone 1gr/12 jam/IV
 POD
Maret, 22 2024 (H+4) Maret, 23 2024 (H+5)

S: S:
Patient feel pain in the left leg Patient feel pain in the left leg

O: O:
BP : 120/80 mmHg BP : 120/70 mmHg
HR: 77 x/mnt HR: 79 x/mnt
Temperature : 36,6° C Temperature : 36,2° C
RR : 19 x/mnt RR : 19 x/mnt
SpO2 : 98% room air SpO2 : 99% room air

Local state : Regio Suralis Sinistra Local state : Regio Suralis Sinistra
Look : Wound covered with gauze, blood (+) Look : Wound covered with gauze, blood (+)
Feel : pain tenderness (+), pain (+) Feel : pain tenderness (+), pain (+)
Move : Active ROM, unlimited Move : Active ROM, unlimited

A: A:
Post debridement H+4 a.i degloving soft tissue injury Post debridement H+5 a.i degloving soft tissue injury
P: P:
IVFD RL 20 tpm pro wound care Inj. IVFD RL 20 tpm pro wound care
Ketorolac 30 mg/8 jam/IV Inj. Ketorolac 30 mg/8 jam/IV
Inj. ceftriaxone 1gr/12 jam/IV Inj. ceftriaxone 1gr/12 jam/IV