Mentor

Dr. dr. Adrian Khu, Sp.OT, FICS

Presentator
Reni Meilansari - 133307010172
PATIENT STATUS

Room Number : 1622

Day / Date of Entry Room : 25 January 2019
Physician in charge : Dr. dr. Adrian Khu, Sp.OT, FICS

PATIENT IDENTITY:
Name : Tn. R
Number Of MR : 08.68.39
Age : 83 years old
Gender : Male
Religion : Christian
ANAMNESA

Main complaint : Patient comes to Emergency Room

Rs. Royal Prima complained of fell
down since 5 days ago.

Previous Disease History : Bell’s Palsy

VITAL SIGN
 General Conditions : Good
 Sensorium / GCS : Compos Mentis/15
 Pulse : 92x/i
 Respiration : 20x/i
 Temperature : 37º C

Primary Survey
 A : Airway clear, no airway
obstruction
 B : RR : 20 x/i
 C : HR : 92 x/i, regular
 D : GCS : 15 (E4V5M6)
 E :T : 37 ºC
GENERAL STATUS
 Head : Normocephali
 Eyes : Pupil: Isokor (+ / +)
 Sclera : Ikterik (- / -)
 Conjunctiva : Anemis (- / -)
 Light reflex : (+ / +)
 Ear : Normal shape, secretions (-)
 Nose : Normal shape, hyperemic konka (-), septal
deviation (-)
 Mouth : Normal shape, cyanosis (-)
 Neck : Lymph nodes enlargement (-)

Thorax (Lungs)
 Inspection : Fusiform symmetrical chest shape
 Palpation : Right = left stem fremitus
 Percussion : Sonor
 Auscultation : Vesikuler
Heart
 Inspection : Ictus cordis is not visible
 Palpation : Ictus cordis palpable
 Percussion : Dim, right and left heart limits cannot be
assessed
 Auscultation : S1S2 normal, Gallop (-), Murmur (-)

Abdomen
 Inspection : Symmetrical
 Palpation : Soepel, tenderness (-), hepatomegaly (-),
splenomegaly (-)
 Percussion : Timpani
 Auscultation : Peristalsis (+) normal impression

Extremity
 Superior : Warm + / +, pain -/-, edema - / -
 Inferior : Warm + / +, pain +/+
ORTHOPEDIC EXAMINATION

 Look
The patient's condition is good

 Feel
Pain (+)

 Move
Pain when moved

Temporary Diagnosis:
Close Fracture (R) Neck of Femur

Recommendation:
- Laboratory examination (complete blood, Liver function,
diabetic, renal function)
Laboratory examination

HEMATOLOGI

No. Pemeriksaan Hasil Satuan Normal

13.3
1 Hemoglobin g/dl 13.5 – 15.5
12,64
2 Leukosit 103/uL 5 – 11
21
3 Laju Endap Darah mm/jam 0 – 20
352
4 Trombosit 103/uL 150 – 450
39,5
5 Hematocrit % 30.5 – 45.0
4.07
6 Eritrosit 10^6/mm3 4.50 – 6.50

7 MCV 63.3 fL 75.0 – 95.0

8 MCH 21 Pg 27.0 – 31.0

9 MCHC 33.1 g/dl 32.0 – 34.0

 RENAL FUNCTION

No Pemeriksaan Hasil Satuan Normal Metode

1 Ureum darah 31 mg/dl 15 - 38 -
2 Kreatinin 0,82 mg/dL 0.55 - 1.30 -

DIABETIC
No. Pemeriksaan Hasil Satuan Normal Metode
1 Glukosa ad Random 147 mg/dL <200 -
RADIOLOGI - Pre Surgery
Work Diagnosis
Crush Injury (D) Ankle

Planning
 Giving IVFD RL fluid 20 gtt / minute macro
 Patients fast before surgery
 Monitoring TD / HR / RR
 - Inj. Ceftriaxone 1gr / 12 hours
 - Inj. Ketorolac 1 amp / 8 hours IV
 - Inj. Ranitidine 1 amp / 12 hours IV
Action
HEMIARTHROPLASTY
1. Supine position under spinal anesthesia
2. Disinfectants and drapping procedures
3. Posterior appereance incision
4. Identification of fractures and
hemiarthroplasty
5. Wash the wound, drainage, close the
wound.
RADIOLOGI - Post Surgery
Post operative Assessment

General condition : Good

Awareness level : awake
Breath : free
Respiratory : spontaneous
Education :
1. Can not do a maneuver that can overcome
the wound, with movements that can
endanger the patient
2. Schedule repeated controls to activate
secondary debridement results.