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  • Jomet Ortho RS Kota Makassar 6 April 2019

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    nadrah
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    Tn. S, a 28-year-old man, presented to the emergency department with left arm pain after a motorcycle accident. Physical examination revealed deformity, edema, and minimal bleeding of the left forearm with tenderness on palpation. X-ray showed a closed fracture of the distal 1/3 of the left ulna. The diagnosis was a closed fracture of the distal 1/3 of the left ulna. The treatment plan was open reduction and internal fixation with a plate and screws followed by intravenous antibiotics, analgesics, and antacids.

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    Tn. S, a 28-year-old man, presented to the emergency department with left arm pain after a motorcycle accident. Physical examination revealed deformity, edema, and minimal bleeding of the left forearm with tenderness on palpation. X-ray showed a closed fracture of the distal 1/3 of the left ulna. The diagnosis was a closed fracture of the distal 1/3 of the left ulna. The treatment plan was open reduction and internal fixation with a plate and screws followed by intravenous antibiotics, analgesics, and antacids.

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    26 views10 pages

    Jomet Ortho RS Kota Makassar 6 April 2019

    Uploaded by

    nadrah
    Tn. S, a 28-year-old man, presented to the emergency department with left arm pain after a motorcycle accident. Physical examination revealed deformity, edema, and minimal bleeding of the left forearm with tenderness on palpation. X-ray showed a closed fracture of the distal 1/3 of the left ulna. The diagnosis was a closed fracture of the distal 1/3 of the left ulna. The treatment plan was open reduction and internal fixation with a plate and screws followed by intravenous antibiotics, analgesics, and antacids.

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    of 10

    BAGIAN ORTHOPEDI

    Nadrah Zuhriah Amri


    111 2017 2085

    Closed Fraktur 1/3 Distal Ulna Sinistra


    CASE
    Identitas Pasien
    REPORT
    PATIENT’S IDENTITY

    Nama : Tn. S
    HISTORY TAKING

    PHYSICAL Umur : 28 tahun / Laki-laki


    EXAMINATION
    Tanggal Masuk : 1 April 2019

    Registration : 263470
    INVESTIGATION

    ASSESMENT

    THERAPY
    CASE
    REPORT
    HISTORY TAKING

    PATIENT’S IDENTITY KU: Nyeri pada lengan kiri


     Anamnesis Terpimpin : Pasien datang ke UGD RS Kota
    HISTORY TAKING
    Makassar dengan keluhan nyeri pada lengan kiri yang
    PHYSICAL dialami sejak tadi malam. Sebelumnya pasien mengalami
    EXAMINATION kecelakaan lalu lintas. Pasien sedang mengendarai sepeda
    motor lalu menabrak mobil yang sedang parkir di pinggir
    jalan. Pasien kemudian jatuh dengan posisi tangan kiri
    INVESTIGATION lebih dahulu menyentuh tanah. Pasien dalam keadaan
    sadar saat terjatuh.Tidak pusing, mual maupun muntah
    ASSESMENT

    THERAPY
    CASE
    PRIMARY SURVEY
    REPORT
    PATIENT’S IDENTITY
    Airway • Bebas

    HISTORY TAKING
    • 20x/min, spontan, symetric ki=ka,
    PHYSICAL
    Breathing sonor pada kedua paru
    EXAMINATION

    • Td 110/80mmHg, Nadi 80x/min,


    Circulation reguler, kuat angkat

    INVESTIGATION • GCS 15(E4M6V5), light reflex +/+ ,


    Disabilty pupil isokor, Ø : 2.5mm/2.5mm,
    ASSESMENT

    THERAPY Exposure • Temp 36,5°C (axilla)


    CASE
    SECONDARY SURVEY
    REPORT
    PATIENT’S IDENTITY  Regio Antebrachii Sinistra
     Look :
    HISTORY TAKING
    Deformitas (+), edema (+), luka (+) perdarahan
    PHYSICAL minimal
    EXAMINATION
     Feel :
    Nyeri tekan (+), hangat (+), pulsasi A. Radialis (+),
    Pulsasi A. Ulnaris (+)
    INVESTIGATION
     Movement :
    ASSESMENT Gerakan aktif dan pasif sulit dinilai karena nyeri
    THERAPY  NVD :
    Sensoris Baik, pulsasi A. Radialis (+), Pulsasi A. Ulnaris
    (+), CRT<2 detik
    CASE
    Laboratorium
    REPORT
    PATIENT’S IDENTITY
    Leukosit 12.300 uL
    HISTORY TAKING

    PHYSICAL Hb 16gr/dl
    EXAMINATION

    Ht 48,3 %
    INVESTIGATION

    ASSESMENT
    Trombosit 194.000
    THERAPY
    CASE
    RADIOLOGY FINDING
    REPORT
    PATIENT’S IDENTITY

    HISTORY TAKING

    PHYSICAL
    EXAMINATION X- Ray
    Antebrachii
    Sinistra
    AP/Oblique

    INVESTIGATION

    ASSESMENT

    THERAPY

    Fraktur 1/3 distal ulna sinistra


    CASE
    DIAGNOSIS
    REPORT
    PATIENT’S IDENTITY

    HISTORY TAKING

    PHYSICAL
    EXAMINATION Closed Fracture 1/3 Distal Ulna
    Sinistra
    INVESTIGATION

    ASSESMENT

    THERAPY
    CASE
    Planning
    REPORT
     Rencana operasi orif dengan plate and screw
    PATIENT’S IDENTITY

    HISTORY TAKING

    PHYSICAL
    Therapy
    EXAMINATION

    • Cefotaxime 1gr /12j/iv


    • Ketorolac 30 mg/8j/iv
    INVESTIGATION
    • Ranitidin 50 mg/ 12j/iv
    ASSESMENT

    THERAPY
    THANK YOU

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