morep bedah 4 february 2015
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stase bedahTRANSCRIPT
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Department of Surgery
February, 04 2015
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DAFTAR OBDAFTAR OB
Mr Joko COS+Fr costae 2-3
Mrs Suryatmi PO trepanasi meningioma
Mrs Masri Abcess Maxilla
Mrs Salamah Cholelithiasis
Mr Sakir Fr Lefort 3
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Name : Mr S Age : 42 y.o Sex : male Address : Lamongan Date examination: february 04, 2015
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ANAMNESIS Chief complaint
Pain in the face
Present Illness
Patient referrals from the Ngimbang hospital after a traffic accident 4
hours before admission. Patient riding a motorcycle and hit a parked car
from behind . patients complained pain in the face. Nausea and vomiting
blood approximately 4 times , bleeding from the nose right and left . The
patient also complained of chest pain and breathing heavy. Patients wear
a helmet and a crash helmet when detached . The patient decrease of
consiousness after accident but the patient remember what happened .
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History illness
allergy (-), HT (-), DM (-)
Family illness :
(-) Social history :
alcohol (-)
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PHYSICAL EXAMINATION PHYSICAL EXAMINATION
VITAL SIGN :
GCS : 456
BP : 101/56 mmHg
PULSE RATE : 118 x/minutes
TEMP : 36,5 oC
RR : 22 x / minutes
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Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (-)
Breathing : spontan, simetric (+), RR 22x/minutes, ves/ves, rh-/-, wh-/-, Sp02 99%
Circulation : PR 76x/minutes, acral warm dry red, CRT < 2”, BP 101/56 mmhg
Disability : GCS 456, Light reflex +/+, isocor pupil 3mm/3mm, lateralisasi-
Exposure : temp 36,5C, Vulnus appertum et regio infra orbita uk 5x0,5 cm, Multiple ekskoriasi et regio antebrachii sinistra, lesion in the thorax (+)
PRIMARY SURVEY
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Head and neck : anemic (-), icteric (-), cyanosis (-), dyspneu (-), bloody rinorrhea +/+, Bloody otorrhea -/-, brill hematom +/+, scalp hematom et regio frontal, floating maxilla (+)
Thorax : simetric (-), retraction (-), lesion +Pulmo : ves/ves, rh-/-, wh-/-Cor : S1S2 single, murmur (-), gallop (-), lession -
Abdomen : soepel, distended (-), tympani (+), liver and spleen were not palpable, bowel sound (+), lession-
Extremities : acral warm, dry, red, lession-
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• Vulnus appertum et regio infra orbita uk 5x0,5 cm
• Vulnus excoriasi et regio mandibulae• Multiple excoriasi et regio antebrachii
sinistra• Lesion in the thorax (+)
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Clue and cue Male, 42 y.o Pain in the face Post traffic accident Vomitting blood Bloody rhinorrhea Chest pain and breathing heavy Brill hematom Floating maxilla Staus localized : Vulnus appertum et regio infra
orbita uk 5x0,5 cm, Multiple ekskoriasi et regio antebrachii sinistra, lesion in the thorax (+)
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Early Early AssesmentAssesment
Epistaxis
Mild brain injury
Fracture of maxilla
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• CBC• CT-BT• GDA • Thorax AP• Head CT scan
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CBCCBCDiff 0/0/86/12/2
Hct 35,2
Hb 12
LED 1/2
Lekosit 21.400
Trombosit 250.000
Serum Creatinin 1,2
RBC 208
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CT SCANCT SCAN
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CT SCAN BONE WINDOWCT SCAN BONE WINDOW
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FOTO THORAXFOTO THORAX
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AssesmentAssesment
Mild brain injury Fracture Le Fort III
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• IVFD Asering loading 500 cc Maintenance Assering 1500 cc/24 hours
• Inj Remopain 3x1 amp• Inj piracetam 4x3 gr IV• Inj tranexamat acid 3x250 mg IV• Inj ceftriaxon 2x1 gr IV• Inj tetagam 250 IU IM
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Subjective complaint Vital sign Sign of increased pressure intracranial
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Explain to the patient’s family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.