Tehnik Penyusunan Status Penderita Bedah

The History and Physical Examination: Comprehensive or Focused?

Comprehensive Assessment 1. Is appropriate for new patients in the office or hospital 2. Provides fundamental and personalized knowledge about the patient 3. Strengthens the clinician-patient relationship 4. Helps identify or rule out physical causes related to patient concerns 5. Provides baselines for future assessments 6. Creates platform for health promotion through education and counseling 7. Develops proficiency in the essential skills of physical examination Focused Assessment 1. Is appropriate for established patients, especially during routine or urgent care visits 2. Addresses focused concerns or symptoms 3. Assesses symptoms restricted to a specific body system 4. Applies examination methods relevant to assessing the concern or problem as precisely and carefully as possible

Differences Between Subjective and Objective Data

Subjective Data
What the patient tells you
The history, from Chief Complaint through Review of Systems

Objective Data
What you detect during the examination
All physical examination findings

Always remember, the data flow spontaneously from the patient, but the task of oral and written organization is yours

The Comprehensive Adult Health History

Identifying Data and Source of the History

Chief Complaint(s)
Present Illness Past History Family History

Personal and Social History

Review of Systems

 Identifying Data
Identifying datasuch as age, gender, occupation, marital status
Source of the historyusually the patient, but can be a family member or friend, letter of referral, or the medical record If appropriate, establish source of referral, because a written report may be needed.

Reliability Chief Complaint(s)

Varies according to the patient's memory, trust, and mood The one or more symptoms or concerns causing the patient to seek care

 Present Illness
Amplifies the Chief Complaint; describes how each symptom developed Includes patient's thoughts and feelings about the illness Pulls in relevant portions of the Review of Systems, called pertinent positives and negatives (see p. 10) May include medications, allergies, habits of smoking and alcohol, which are frequently pertinent to the present illness

 Past History
Lists childhood illnesses

Lists adult illnesses with dates for at least four categories: medical; surgical; obstetric/gynecologic; and psychiatric
Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety

Family History
Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents

Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, etc

 Personal and Social History

Describes educational level, family of origin, current household, personal interests, and lifestyle

Review of Systems
Documents presence or absence of common symptoms related to each major body system

 Review of Systems.
Understanding and using Review of Systems questions are often challenging for beginning students. Think about asking a series of questions going from head to toe.
It is helpful to prepare the patient for the questions to come by saying, The next part of the history may feel like a hundred questions, but they are important and I want to be thorough. Most Review of Systems questions pertain to symptoms, but on occasion some clinicians also include diseases

Cardinal Techniques of Examination

1. Inspection Close observation of the details of the patient's appearance, behavior, and movement such as facial expression, mood, body habitus and conditioning, skin conditions such as petechiae or ecchymoses, eye movements, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait.

2. Palpation Tactile pressure from the palmar fingers or fingerpads to assess areas of skin elevation, depression, warmth, or tenderness; lymph nodes; pulses; contours and sizes of organs and masses; and crepitus in the joints

3. Percussion Use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand laid against the surface of the chest or abdomen, to evoke a sound wave such as resonance or dullness from the underlying tissue or organs. This sound wave also generates a tactile vibration against the pleximeter finger

4. Auscultation Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity. For the heart this involves sounds from closing of the four valves and flow into the ventricles as well as murmurs. Auscultation also permits detection of bruits or turbulence over arterial vessels

 As you listen to patients and examine them, you begin to cluster information into patterns that fall into a list of problems, termed Assessment or Impression. In a well-constructed record, each problem is listed in order of priority, clarified by an explanation of supporting findings and a differential diagnosis, and followed by a Plan for addressing that problem. Plans are often wide-ranging, from tests needed to patient education, a change in medication, referral to another clinician, or a return visit for counseling and support.

 Identifying Problems and Making Diagnoses: Steps in Clinical Reasoning

Identify abnormal findings. Localize findings anatomically. Interpret findings in terms of probable process. Make hypotheses about the nature of the patient's problem. Test the hypotheses and establish a working diagnosis. Develop a plan agreeable to the patient

Penyusunan Status Trauma

1. Identitas Penderita

2.
3. 4.

Waktu Kejadian Waktu Kedatangan

Mode of Injury Inisial Assessment, Primary Survey dan Secondary Survey (termasuk anamnesa adanya riwayat penyakit dahulu, adanya penyakit penyerta, penggunaan obatobatan, makanan,dll)

5.

Status Generalis

6.
7.

Status Lokalis
Assessment (Diagnosis Kerja, Diagnosis Banding, Diagnosis Sekunder, Diagnosis Komplikasi)

8.

Planning (Diagnosis, Terapi, Monitoring, Edukasi)

Status Lokalis (look, listen, feel)

Regio yang terkena trauma (jejas, hematom, luka

terbuka, adanya perdarahan)

Trauma orthopedi
Ada tidaknya Deformitas jaringan Ada tidaknya Nyeri tekan atau adanya krepitasi Status neurologis (GCS, kelumpuhan extremitas dan denyut nadi di bawah level trauma)

 Trauma Kepala
Ada tidaknya Deformitas jaringan
Ada tidaknya Nyeri tekan atau adanya krepitasi Status neurologis (GCS, kelumpuhan extremitas)

Perdarahan dari telinga, hidung atau mata

Trauma maksilofasial Hati2 dengan cidera leher

 Trauma Thoraks
Ada tidaknya Deformitas jaringan
Ada tidaknya Nyeri tekan atau adanya krepitasi Evaluasi pergerakan dada

Lakukan palplasi, perkusi, auskultasi di seluruh paru dan bandingkan kanan dengan kiri
Awas bila penderita bertambah sesak

 Trauma Abdomen
Lokasi jejas dan hematom
Lakukan palpalsi, auskultasi dan perkusi Ada tidaknya cairan bebas, udara bebas, atau defans muskular Colok Dubur untuk mengevaluasi adanya trauma di daerah pelvis dan urethra posterior

Evaluasi kestabilan sacroiliac joint

Pemasangan kateter urine

Penyusunan Status Luka Bakar

1. 2. 3. 4. Identitas Penderita Waktu Kejadian Waktu Kedatangan Mode of Injury (electric injury, trauma inhalasi) Inisial Assessment, Primary Survey dan Secondary Survey

5.
6.

Penentuan derajat dan luas persentaseluka bakar

Pemberian cairan baxter sesuai dengan persentase luka bakar

6. Status Generalis 7. Status Lokalis 8. Assessment (Diagnosis Kerja, Diagnosis Banding, Diagnosis Sekunder, Diagnosis Komplikasi)

9.

Planning (Diagnosis, Terapi, Monitoring, Edukasi)

Penyusunan Status Onkologi

1. Identitas Penderita

2.

Anamnesa (Riwayat Penyakit dahulu, Riwayat Penyakit sekarang, Riwayat Pekerjaan, Riwayat Penyakit Keluarga, Riwayat Sosial, Pola Hidup) Status Generalis
Status Lokalis Assessment (Diagnosis Kerja, Diagnosis Banding, Diagnosis Sekunder, Diagnosis Komplikasi) Planning (Diagnosis, Terapi, Monitoring, Edukasi)

3.
4. 5. 6.

Status Lokalis

Lokasi Tumor Ukuran Tumor Konsistensi Tumor Batas Tumor Pembesaran Kelenjar Getah Bening (KGB) Regional Adanya nyeri atau tidak Adanya cairan, Bau dan warnanya Komplikasi dari Tumor

Penyusunan Status Urologi

1. 2. Identitas Penderita Anamnesa (Riwayat Penyakit dahulu, Riwayat Penyakit sekarang, Riwayat Pekerjaan, Riwayat Penyakit Keluarga, Riwayat Sosial, Pola Hidup) Status Generalis Status Lokalis Assessment (Diagnosis Kerja, Diagnosis Banding, Diagnosis Sekunder, Diagnosis Komplikasi) Planning (Diagnosis, Terapi, Monitoring, Edukasi)

3. 4. 5.

6.

 Pemeriksaan Status Urologis

Flank Mass Nyeri ketok CVA Vesica Urinaria dan Abdomen Skrotum dan Testis Penis Colok Dubur

Planning
Diagnosis
1. 2. 3. Laboratorium Radiologi Patologi Anatomi

Terapi
1. Medikamentosa

2.

Pembedahan
Vital Sign Perubahan dari kondisi penderita, terutama pada lokasi yang mengalami trauma Intake dan output cairan

Monitoring
1. 2. 3.

 Edukasi
Handycap yang terjadi
Waspada terhadap adanya komplikasi lanjut Pola makanan

Jika direncanakan untuk adanya terapi lanjutan seperti operasi tahap ke 2, rehabilitasi fisik dan mental, kemoterapi, dll

 Referensi

Bickley, Lynn S.; Szilagyi, Peter G ; Bates' Guide to

Physical Examination and History Taking, 10th Edition