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Laporan Jaga29 Agustus 2015

Konsulan : dr. Fitri, SpAn

IF/ZI/JT/WM/FI/DY/AQ/AY/BD/IE

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IDETITAS

Nama:

Nn. Desi, 23 th

Dx : OF metatarsal digitiII pedis sinistra prodebridement

Anamnesa :

  Seorang wanita datang dengankelhan n!eri pada kaki kirisetelah ter"ath dari motor # "am S$%S. &erbentr di kepala'(), os pakai helm. *akirobek, n!eri. +ingsan '), mal

'), mntah ').

AAMESA

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!ri"ar# Sur$%#

A : patensi hidng -(, &$D /0m,

malampati I, bka mlt 3 "ari1: %% 2 x -menit

I: +ergerakan dada kanankiri

+: 4remits raba kanan kiri

+: Sonor-SonorA: SD5 (-( S& -

 6: N: 78 x-menit, &ensi 99-7 mmg D: ;6S

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AlloanamnesaAllerg! : disangkal$edi0ation : disangkal+ast Illness : disangkal>ast $eal : / "am pre op

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S%&ondar# Sur$%#  *@ : ;6S

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'EM( )rit%ria

> 'look externall!) : < 'e?alate) : bka mlt 3 "ari, "arak

os h!oid mental 3 "ari, "arak os th!roidke h!oid 2 "ari

$ 'malampati) : I

O 'obstr0tion) : N 'ne0k mobilit!) : gerak leher bebas

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'a* t+l - 012

• b : 99,7• t : 37• A> : 9/,3• A& : 28• A< : =,9• ;DS : 929• +& :93,=• A+&& :32,#• IN% : 9,

Na :93* :3,86l :9/• 1sAg :'N%)• ;ol darah : A1

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!EDIS A! DA (B'.

Fraktr sha4tmetatarsal II pedis

sinistra

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  ;6S :

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DIA8(SA AESTESI('(8I

Wanita, 9 ta4un d%n+an (F

"%tatarsal di+iti II p%dis sinistra prod%*rid%"%n d%n+an status isi3 ASAIIE plan 6ASAB

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!6(B'EM

>ekositosis

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!ot%nsial !ro*l%"

Osteomielitis

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!r% (p%rasi Durant% (p%rasi

  *@ : sedang  & : 9#-mmg  N : 8 x-menit  %% : 22x-mnt  S : 3/,8o6

  11 : #9 kg

A+%n SAB

1pi?a0ain 9 mg

intratekal

  Anestesi : 2.=# 29.9#  Operasi : 2.# 29.9  +osisi : spine

  Obat $ask drante O+  Ondan0entron = mg  *etorola0 3 mg

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Balan&% )airan Durant% (p%rasi

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86AFIK 7EM(DIAMIK D56ATE (!

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Balan&% )airan Durant% (p%rasi

Inpt Otpt 1alan0e

am *ris *ol Drh Drh @rin SO($

2.=#

29.9

= 9 =# 9#3 (972

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!(ST (!E6ASI BA8SA'

*esadaran : 6$&ensi : 99-7mmgNadi : 8x-menit%% : 2x-menitN%S : 9

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AA'8ESI !(ST (!E6ASI

Analgetik post op :

  *etorola0 3x3 mg

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Terima Kasih