Duty Report 24 Des.docx

DUTY REPORT DECEMBER 24th 2018

A. PATIENTS LIST In emergency installation we received 2 surgical patients, which are: No 1.

2.

Name/Age Mr. S/50 years old

Diagnosis

Management

Closed fracture of left

Splint application

antebrachii e.c traffic

X ray left antebrachii AP and

accident 2 hours before

lateral view

admission

Ketorolac 30mg/8 jam

Excoriate wound at regio manus sinistra

Wound toilet

Mr. T / 53 years

Closed fracture of left

Immobilitation

old

clavicle e.c traffic

X ray chest AP

accident 2 hours before

Ketorolac 30mg/8 jam

admission

Pro ORIF

Pro ORIF

B. CASE REPORT1 I.

PATIENT IDENTITY Name

: Mr. S

Age

: 50 years old

Gender

: male

Occupation : construction laborer

II. PRIMARY SURVEY ▰ Airway and C spine control Speak clearly, no snorng, no gargling, no stridor, no neck pain Airway and C-spine control  CLEAR ▰ Breathing and ventilation

Respiratory rate: 18x/minute, reguler, adequate inspiration, chest symmetry in static and dynamic, no injury, no retraction Breathing and ventilation  ADEQUATE ▰ Circulation and hemorrhage control Pulse rate 80x/minute, regular, enough tone and volume, no cyanosis, no active bleeding, no cold acral, capillary refill time <2”, blood pressure 110/80 mmHg Circulation dan Hemorrhage control  STABLE ▰ Disability GCS 15 (E4M6V5) , isocoric pupil, diameter 3mm/3mm, round, light reflex (+/+), neurology deficit (-) ▰ Exposure No life-threatening injury

III. SECONDARY SURVEY ANAMNESIS Autoanamnesis with patient in the emergency instalation on December 24th 2018 at 22.00 WIB Chief complain

: pain on the left arm

History of illness

:

± 2 hours ago before admission, patient experienced traffic accident while trying to avoid a cat on the street. Patient rode the motorcycle with his neighbor sit behind. Both of them fell off from the motorcycle with the left side of the body bumped to the street first. He couldn’t tell the exact position of his left arm when he fell, but he only recall that his left arm bumped to the street and pinned under motorcycle. After the accident patient felt pain on his left arm and couldn’t move his arm. Patient used helmet, he denied any head bump, syncope, bleeding, dizziness, vomiting, and nausea. History of past illness: History of past trauma (-) History of hypertension (-) History of diabetes mellitus (-) History of allergic (-)

History of operation (-) History of family illness: History of hypertension (-) History of diabetes mellitus (-) History of allergic (-) History of social and economic state Patient is a contruction laborer which use BPJS PBI for paying hospital bill. PHYSICAL EXAMINATION ◦

General condition

: Moderately ill

◦

Consciousness

: Composmentis, GCS 15 (E4M6V5)

◦

Vital signs Respiratory rate : 18x/minute (regular, enoughi in depth, retraction (-)) Pulse rate

: 80x/minute (regular, enough tone and volume)

Blood pressure : 110/80 mmHg

◦

Temperature

: 37,7o C (Axiller)

VAS

:5

General status Eye

: Conjunctiva anemic (-/-)

Nose

: rhinorrhage (-/-), rhinorhea (-/-), injury (-), deformity (-)

Ear

: otorrhage (-/-), otorrhea (-/-), othematome (-/-), injury (-)

Mouth

: cyanotic lips (-), dry lips (-), injury (-), bleeding (-)

Neck

: Injury (-), trachea deviation (-)

Chest Lung Inspection

: symetric at static and dynamic, no injury, no retraction

Palpation

: tactile fremitus was equal on both side

Percussion

: sonor on all area

Auscultation : vesicular breath sound (+/+), no additional breath sound Heart Inspection

: Ictus cordis was not seen

Palpation

: palpable Ictus cordis at 5th ICS, 2 cm medial LMCS

Percussion

: normal configuration

Auscultation : heart sound normal, reguler, no gallop, no murmur Abdominal

Inspection

: flat, injury mark (-), bowel pattern/movement unseen

Auscultation : bowel soung (+) normal Palpation

: tenderness (-), liver and spleen not palpable

Percussion

: tympani, liver dullness (+), shifting dullness (-)

Extremitas

Inferior

Cyanosis

-/-

-/-

Cold Acral

-/-

-/-

<2”/<2”

< 2”/<2”

Capillary Refill Time ◦

Superior

Local Status (antebrachii sinistra) Look : redness (-), swelling (+), deformity (+), bleeding (-), vulnus excoriatum (+) at dorsum manus sinistra Feel

: tenderness (+), crepitation (-), bone irregularity (+), axial pain (+), radialis pulse (+), sensoric sensation (+), hipesthesi (-)

Move : flexion-extention of the finger (+), limited wrist-elbow movement due to pain

IV. CLINICAL PRESENTATION

V. CLINICAL DIAGNOSIS Suspect closed fracture of the left antebrachi

VI. INITIAL PLAN • Ip Dx

S:O : routine blood test, X photoAP and lateral of left antebrachial regio

• Ip Tx: – wound toilet – Splint application – Ringer lactat infussion 20 dpm – Ketorolac 1 amp/8 hours intravenous injection – ATS 1ampul – Ceftriaxon 1 gram/ 12hours intravenous injection • Ip Mx : Pain, wound condition • Ip Ex : Giving information about patient condition which his arm bone was broke and asking consent for hospitalisation in preparation of further correction by doing surgical procedure in order to repair bone position.

VII.RADIOLOGY

There is bone dyscontinuity of radius sinistra at 1/3 middle shaft with distal fragment displaced to dorsal aspect, surrounded by soft tissue swelling and radioulnar dislocation.

VIII. DIAGNOSIS Complete closed fracture of radius sinistra 1/3 middle shaft non complicata with radioulnar dislocation IX.

TREATMENT Pro Open Reduction Internal Fixation

C. CASE REPORT2 I.

PATIENT IDENTITY Name

: Mr. T

Age

: 53 years old

Gender

: male

Occupation : construction laborer

II.

PRIMARY SURVEY ▰ Airway and C spine control Speak clearly, no snorng, no gargling, no stridor, no neck pain Airway and C-spine control  CLEAR ▰ Breathing and ventilation Respiratory rate: 20x/minute, reguler, adequate inspiration, chest symmetry in static and dynamic, no injury, no retraction Breathing and ventilation  ADEQUATE ▰ Circulation and hemorrhage control Pulse rate 88x/minute, regular, enough tone and volume, no cyanosis, no active bleeding, no cold acral, capillary refill time <2”, blood pressure 130/80 mmHg Circulation dan Hemorrhage control  STABLE ▰ Disability GCS 15 (E4M6V5) , isocoric pupil, diameter 3mm/3mm, round, light reflex (+/+), neurology deficit (-) ▰ Exposure No life-threatening injury

III. SECONDARY SURVEY ANAMNESIS Autoanamnesis with patient in the emergency instalation on December 24th 2018 at 22.00 WIB Chief complain

: pain on the left shoulder

History of illness

:

± 2 hours ago before admission, patient experienced traffic accident while trying to avoid a cat on the street. Patient got a ride whose position sit behind his neighbor who riding motorcycle. Both of them fell off from the motorcycle with the left side of the body bumped to the street first. He fell with his left shoulder and chest bumped to the street. After the accident patient felt pain on his left shoulder and couldn’t move his arm. Patient used helmet, he denied any head bump, syncope, bleeding, dizziness, vomiting, and nausea. History of past illness: History of past trauma (-) History of hypertension (-) History of diabetes mellitus (-) History of allergic (-) History of operation (-) History of family illness: History of hypertension (-) History of diabetes mellitus (-) History of allergic (-) History of social and economic state Patient is a contruction laborer which use BPJS PBI for paying hospital bill. PHYSICAL EXAMINATION ◦

General condition

: Moderately ill

◦

Consciousness

: Composmentis, GCS 15 (E4M6V5)

◦

Vital signs Respiratory rate : 20x/minute (regular, enoughi in depth, retraction (-)) Pulse rate

: 88x/minute (regular, enough tone and volume)

Blood pressure : 130/80 mmHg

◦

Temperature

: 36,8o C (Axiller)

VAS

:5

General status Eye

: Conjunctiva anemic (-/-)

Nose

: rhinorrhage (-/-), rhinorhea (-/-), injury (-), deformity (-)

Ear

: otorrhage (-/-), otorrhea (-/-), othematome (-/-), injury (-)

Mouth

: cyanotic lips (-), dry lips (-), injury (-), bleeding (-)

Neck

: Injury (-), trachea deviation (-)

Chest Lung Inspection

: symetric at static and dynamic, no injury, no retraction

Palpation

: tactile fremitus was equal on both side

Percussion

: sonor on all area

Auscultation : vesicular breath sound (+/+), no additional breath sound Heart Inspection

: Ictus cordis was not seen

Palpation

: palpable Ictus cordis at 5th ICS, 2 cm medial LMCS

Percussion

: normal configuration

Auscultation : heart sound normal, reguler, no gallop, no murmur Abdominal Inspection

: flat, injury mark (-), bowel pattern/movement unseen

Auscultation : bowel soung (+) normal Palpation

: tenderness (-), liver and spleen not palpable

Percussion

: tympani, liver dullness (+), shifting dullness (-)

Extremitas

Inferior

Cyanosis

-/-

-/-

Cold Acral

-/-

-/-

<2”/<2”

< 2”/<2”

Capillary Refill Time ◦

Superior

Local Status (regio left shoulder) Look : redness (-), swelling (+) in the middle clavicle regio, deformity (+) in the middle clavicle regio, bleeding (-), vulnus (-) Feel

: tenderness (+), crepitation (-), bone irregularity (+), brachial pulse (+), sensoric sensation (+), hipesthesi (-)

Move : flexion-extention of the finger (+), dorso-palmar flexion of the wrist (+), flexion-extention and pronation-supination elbow (+), limited shoulder movement due to pain

IV.

CLINICAL PRESENTATION

V.

CLINICAL DIAGNOSIS Suspect closed fracture of the left clavicle

VI.

INITIAL PLAN • Ip Dx

S:O : routine blood test, X photoAP and lateral of left shoulder, Xphoto thorax

• Ip Tx: – wound toilet – figure of eight application – Ringer lactat infussion 20 dpm – Ketorolac 1 amp/8 hours intravenous injection • Ip Mx : Pain, wound condition • Ip Ex :

Giving information about patient condition which his clavicle bone was broke and asking consent for hospitalisation in preparation of further correction by doing surgical procedure in order to repair bone position.

VII. RADIOLOGY

There is bone dyscontinuity of clavicula sinistra at 1/3 middle shaft, surrounded by soft tissue swelling

VIII. DIAGNOSIS Complete closed fracture of clavicula sinistra 1/3 middle shaft non complicata IX.

TREATMENT Pro Open Reduction Internal Fixation