Status Pemeriksaan Pasien Fraktur

8/12/2019 Status Pemeriksaan Pasien Fraktur

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CLOSED FRACTURE CRURIS DEKSTRA 1/3 PROXIMAL

STATUS PEMERIKSAAN PASIEN

DEPARTEMEN BEDAH

I. Identitas Pasien

Nama : Tn. X

Umur : 21 Tahun

Jn!" K#am!n : La$!%#a$!

A#ama& : %

A'ama : %

S&a&u" : %

P$r(aan : %

Tan''a# ma"u$ RS : 1) A'u"&u" 2*13

Ruan'an : %

N+ MR : %

II. Anamnesis

Anamn"!" ,!#a$u$an "-ara au&+anamn"!" a,a &an''a# 1) A'u"&u" 2*13 u$u# *0.**

I. ,! RSAL Dr M!n&+har(+.

Keluhan Utama

Pa"!n ,a&an' a"-a KLL ,n'an $#uhan mmar a,a $a#a a'!an #a$an' ,!"r&a!

!n'"an "#ama 0 mn!&. Pn,r!&a mn'#uh ""a$ naa" ,an n4r! a,a ,a,a $anan. S#a!n

!&u ,!,aa&$an (u'a ,5+rm!&a" a,a "n,! an''u# $anan 4an' "an'a& "a$!& $a#au "n,!

an''u# ,!'ra$$an.

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Anamnesa Lengkap

Pa"!n #a$!%#a$! 21 &ahun ,a&an' ,n'an $-#a$aan #a#u #!n&a" "a&u (am 4an' #a#u.

P!n'"an "#ama 0 mn!& &!,a$ mun&ah%mun&ah n,r!&a #ua aa 4an' aru &r(a,! a,a

mmar a,a $a#a a'!an #a$an' r,arahan a,a mu#u& h!,un' ,an !n'a &!,a$ a,a.

Pn,r!&a &ama$ ""a$ na5a" ,an &ra"a n4r! a,a ,a,a $anan. Dan n,r!&a (u'a

mn'#uh$an $#a!nan n&u$ a,a "n,! an''u# $anan 4an' "an'a& "a$!& $a#au "n,!

an''u# ,!'ra$$an.

III. Pemeiksaan !isik

A. Keadaan Umum

K"an "a$!& : Tama$ "a$!& ra&

K"a,aran : C+m+" Mn&!"

S&a&u" '!6! : : 0* $'

T : 17* -m

IMT : 1803 $'/m29'!6! -u$u

Cara rar!n' ,an m+!#!&a" :Tidak akti"

S!$a : K++ra&!5

B. Tanda #ital

T$anan ,arah: 8*/)* mm;'

Na,! : 12*


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$. Status genealis

Kulit

arna : Sa=+ ma&an' u-a& 9% "!an+"!" 9% !$&r!$ 9% ruam 9% 55#+r"n"! 9%

Tur'+r : a!$

Suhu : Traa han'a&

L"! : T!,a$ &r,aa& #"!

Kepala

n&u$ : N+rm+-ha#! &!,a$ &r,aa& ,5+rm!&a"

Ramu& : Ramu& r=arna h!&am &a# #uru" ,!"&r!u"! mra&a &!,a$ mu,ah ,!-au&

%a&ah

In"$"! : S!m&r!" u-a& 9%' "!an+"!" 9% ,an !$&r!$ 9% +,m 9%

Mata

o K,u,u$n $,ua +#a ma&a "!m&r!"

o K#+a$ ma&a: P&+"!" 9% E,ma 9%

o K+n(un'&!>a u-a&()(

o S$#ra I$&r!$ %/%

o Pu!#: I"+$+r &! ra&a ,!am&r 0 mm r5#< -aha4a #an'"un' ?/? r5#< -aha4a

&!,a$ #an'"un' ?/?

o E$"+5&ha#mu" 9% ,an N4"&a'mu" 9%

o @ra$an +#a ma&a a!$

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Telinga

N+rm+&!a n4r! &ar!$ %/% n4r! &$an &ra'u" %/% ma&u" a$u"&!$u" $"&rnu" #aan' ?/?

"rumn %/% "$r& %/% mmran &!man! !n&a$ ?/? r,arahan 9%/%

Hidung

n&u$ n+rma# &!,a$ &r,aa& ,5+rm!&a" ,>!a"! "&um 9% "$r& %/% mu$+"a

h!rm!" %/% r,arahan -a>um na"! %/%

Bi*i

n&u$ n+rma# "!m&r!" &!,a$ &ama$ $r!n' &!,a$ &ama$ "!an+"!" mu$+"a !!r a&a"

,an a=ah &!,a$ h!rm!".

Mulut

Ora# h4'!n a!$ $ar!" %/% '!'! +m+n' %/% #!,ah &!,a$ &ama$ $+&+r #an'!&%#an'!&

n+rma#

Tengg++kan

T+n"!# T1%T1 &!,a$ h!rm!" $r!&a &!,a$ m#ar ,&r!&u" %/% #!,ah n+rma# u>u#a

,!&n'ah ar-u" 5ar!n' "!m&r!" mu$+"a 5ar!n' &!,a$ h!rm!" ,an &!,a$ 'ranu#r.

Lehe

Tra$a &raa ,!&n'ah JP 0?2 -m;2O $#n(ar '&ah n!n' &!,a$ &raa mm"ar

&!r+!, &!,a$ &raa mm"ar.

Th+aks

Paru-paru

In"$"! : N+rm-h"& ,!n,!n' ,a,a "!m&r!" a!$ "&a&!" ,an ,!nam!"

&! rna5a"an &h+ra-a#% a,+m!na# r&ra$"! "#a !'a 9%.

Pa#a"! : @ra$an ,!n,!n' ,a,a "!m&r!" >+-a# 5rm!&u" "!m&r!" $anan ,an $!r!

Pr$u"! : S+n+r ,!$,ua #aan' aru

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Au"$u#&a"! : "!$u#r ?/? rh %/% =h %/%

Jantung

In"$"! : T!,a$ &ama$ u#"a"! !$&u" -+r,!"

Pa#a"! : Traa !$&u" -+r,!" a,a ICS 1 -m m,!a# ,ar! #!na m!,$#a>!$u#a $!r!

Pr$u"! : a&a" (an&un' $anan : ICS III % #!na "&rna#!" ,


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K!r! : S!m&r!" "!an+"!" 9% ,ma 9% a$ra# han'a& ,5+rm!&a" 9% $r!&a"! 9% n4r!

9% a&r+5! +&+& 9% "n,! &!,a$ a,a $#a!nan. 'ra$an a$&!5.

Ekstemitas *a,ah

Kanan : L!ha& "&a&u" #+$a#!"

K!r! : S!m&r!" "!an+"!" 9% ,ma()( a$ra# han'a& ,5+rm!&a" 9% $r!&a"! 9% n4r!

9% a&r+5! +&+& 9% "n,! &!,a$ a,a $#a!nan 'ra$an a$&!5

D. Status L+kalis - Regi+ $uis Deksta '

L++$

S$!n : Lu$a #-& 9? =arna mrah $!ruan ,!"$!&ar #u$a #u$a &ru$a 9%

Sha : O,m 9? ,5+rm!&a" 9?

P+"!&!+n : Ma#+"!"! 9?

F#

S$!n : N4r! &$an 9? a$ra# han'a& 9?

S+5& T!""u: O,m 9? A&r+5! +&+& 9%

+n : Kr!&a"! 9?

Pu#" : A. ,+r"a#!" ,!" &raa #mah

M+>

A$&!5 : Tr,aa& ma&a"an 'ra$ $arna n4r!

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Pa"!5 : Tr,aa& ma&a"an 'ra$ $arna n4r!

P+=r : Su#!& ,!n!#a! $arna n4r!

I#. Pemeiksaan Penun&ang

. Pemeiksaan la*+at+ium tanggal /0 Agustus 1/2

Paamete Nilai Nilai Ru&ukan Satuan

Daah Lengkap

Lu$+"!& .3// 0 B 1* 1*3/uL

Er!&r+"!& )8 )0 % 00 1*7/mm3

;m+'#+!n 1 1) B 17 '/,L

;ma&+$r!& 38 3 B )7

Tr+m+"!& 28.*** 10* B )** 1*3/mm3

Kimia Daah

S@OT 3) 30 U/L

S@PT )* )1 U/L

Urum 22 1 B )3 m'/,#

Cra&!n!n * *7 B 1 m'/,#

Hemat+l+gi

#,!n' &!m 2G**H 1 B 7 Mn!&

C#+&h!n' &!m 11G**H 1* B 17 Mn!&

4ula Daah

@#u$+"a S=a$&u 1* 2** m'

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1. Pemeiksaan Radi+l+gis

F+&+ r+n&'n -rur!" ,$"&ra &an''a# *) A'u"&u" 2*13

Deskipsi 5

% Jn!" 5+&+ : AP%La&ra#

% S'! $+n5!'ura"!n4a : Fra$&ur $+m#!& -+mm!nu&!5 +" &!!a ,an 5!u#a ,$"&ra 1/3

r+

% S'! $,u,u$ann4a : Fra$&ur a,a +" &!!a ,an 5!u#a ,$"&ra 1/3 r+

,!"#a-, 9?

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% D!"#+$a"! "n,! : D!"#+$a"! "n,! 9%

Kesan

C#+", Fra-&ur +" &!!a ,an 5!u#a ,$"&ra 1/3 r+

F+&+ R+n&'n &h+ra< PA

Deskipsi 5

% S!nu" ,!a5ra'ma #ura ,an -+r a!$ &!,a$ &ama$ 5u"!

% A+r&a : a!$ &a$ m#ar

% Pu#m+ : C+ra$an r+n-h+>a"-u#r ,an h!#u" a!$

Ta$ &ama$!n5!#&ra& / $a>!&a" a&au #"! a&+#+'!" #a!n

% Tu#an'%&u#an' ,an "+5& &!""u a!$

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Kesan 5 C+r ,an u#m+ &a$ &ama$ $#a!nan

#. Resume

an!&a 2* &ahun ,a&an' $ Un!& @a=a& Darura& 9U@D RSAL Dr M!n&+har,(+ ,n'an

$#uhan n4r! a,a &un'$a! a=ah "#ah $anan a$!a& $-#a$aan #a#u #!n&a" "(a$ 10

mn!& SMRS. Pa"!n mn'a#am! $-#a$aan "=a$&u mn'n,ara! m+&+r a,a =a$&u !&u

a"!n r&ara$an ,n'an m+!# ,ar! arah 4an' r#a=anan 4an' mn'a$!a&$an a"!n

&r(a&uh $ arah $anan "h!n''a &un'$a! $anan &r&!ma m+&+r a"!n. S"aa& "ah (a&uh

a"!n ,a#am $a,aan "a,ar ",!$!& u"!n' &!,a$ mn'a#am! mua# ,an mun&ah. Pa"!n

mn'#uh &!,a$ !"a mn''ra$$an $a$! $anann4a $arna n4r! ,an &!,a$ !"a r(a#an.

Tama$ #u$a #-& a,a &un'$a! a=ah $anan $a#a &!,a$ &rn&ur &!,a$ $#uar ,arah ,ar!

h!,un' mu#u& !n'a &!,a$ ""a$ na5a" ,an an''+&a &uuh 4an' #a!n ma"!h ,aa& ,!'ra$an.

Pa,a mr!$"aan 5!"!$ "&a&u" #+$a#!" ,arah -rur!" ,$"&ra ,!,aa&$an #u$a #-& =arna

mrah $!ruan ,!"$!&ar #u$a +,m 9? ,5+rm!&a" 9? ma#+"!"! 9? n4r! &$an 9?

$r!&a"! 9? a. ,+r"a#!" ,!" &raa #mah &r,aa& ma&a"an 'ra$ a$&!5 ,an a"!5

$arna n4r!. Pa,a mr!$"aan ra,!+#+'!" &ama$ 5ra$&ur +" &!!a ,an 5!u#a ,$"&ra 1/3

r+

#I. Diagn+sa Ke&a

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C#+", Fra-&ur Crur!" D$"&ra 1/3 Pr+

#II.Diagn+sa Banding

%

#III.Penatalaksanaan

M,!$amn&+"a

IFD RL 2* &&"/m

An&! &&anu" TT

C5&r!a$"+n 2 < 1

K&+r+#a- 3 < 1 am

N+n M,!$amn&+"a

Pra!$an $a,aan umum ,an r"!aan +ra"!

Ora&!5 : ORIF #a& "-r=

I6. P+gn+sis

a. A, >!&am : a, +nam

. A, 5un'"!+nam : ,u!a a, +nam

-. A, "ana&!+nam : ,u!a a, +nam

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Status Pemeriksaan Pasien Fraktur

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