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SELAMA CC BERLANGSUNG

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NO GADGET NO FOOD & DRINK


Visi Program Studi
Ilmu Bedah
• Menjadi Program studi dokter spesialis ilmu
bedah bereputasi International,
BEDA menghasilkan lulusan profesional, unggul di
bidang penanganan multiple trauma dan
H kanker lini pertama
Misi Program Studi Ilmu Bedah

Menyelenggarakan pendidikan Berkualitas, berdasarkan


kurikulum KIBI dengan memberikan keunggulan pada
penanganan multiple trauma dan kanker lini pertama

BEDA Mengembangkan Penelitian dan pengabdian di bidang Ilmu


Bedah khususnya penanganan multiple trauma dan kanker
lini pertama
H
Menyelenggarakan tata kelola program studi Berbasis Good
University Governance, menuju institusi bereputasi
Internasional
LAPORAN JAGA
Hari jum`at, 8 Mei 2020

Chief : dr. Donny Artya Kesuma


Jaga 3 : dr. Aulia (ATH), dr. Kurniadi (DDI)
Jaga IGD : dr. Alia (ADE), dr. Siwi (SIW)
dr. Taufik (THD), dr. Ardi
(NOV)
Jaga IPI / Bangsal : dr. Adly (DLY)
REKAP KUNJUNGAN IGD

Rawat Inap
No Identitas Diagnosa Tindakan
1. Mrs. S CF of 1/3 Distal Right Shaft IVFD. RL 20 dpm
73 yo Femur Spiral Type Ketorolac inj 30 mg/8hr
01503622 Hypertension grade II Routine Blood Examination
Geriatric Chest X-ray
Porotic Bone Right Femur X-ray
Pelvic X-ray

Orthopedic
Immobilization with skin traction
ORIF Femur Elective (Locking
Plate)
Consult to Internal Medicine
Department Sub Geriatric
Rawat Jalan
No Identitas Diagnosis Keterangan
1 Ny. S Contusio musculorum R. Asam Mefenamat 3 x 500mg
75 th Femur (S)
01493886
2 Tn. S Dx Emergency : Retensi Rawat Jalan
61 th Urine Pulang bawa DC
00942649 Dx Primer : BPH Work Up Dx dari Poli
Dx Lain : -
Dx Komplikasi : -

Pavilliun

No Identitas Diagnosis Keterangan


- - - -
Konsulan
No Identitas Diagnosis Tindakan

- - - -

Meninggal
No Identitas Diagnosis Keterangan

APS
No Identitas Diagnosis Keterangan
- - - -
Name : Mrs. S
Age : 73 y.o
Med. Record: 01503622
Payment : National Health Insurance
Chief Complaint :
Pain on right thigh

Present Illness :
Ten hours prior to admission while the patient was walking on her
house, suddenly she was slipped and fell down. She fell down with her
right thigh hit the corner of the floor. Unconsiousness (-), vomit (-),
convulsions (-). After the incident, the patient complained about pain
on her right thigh and gotten worse by movement. By her family, she
was taken to RSDM.

Past Illness :
History of HT (+)
History of DM (-)
History of ambulation : she can walk without walking aids
Covid 19 screening:
Flu like symtoms (-)
History of fever and malaise (-)
Sore throat (-)
History of traveling (-)
Contact with covid patients (-)
Vesicular breath sound (+/ +)
Body tempt 36.3 °C

EWS Score : 1
Primary Survey

A : Clear
B : I : chest expansion right = left, RR: 20 x/min
P : crepitation (-/-)
P : Sonor/Sonor
A : vesicular breath sound (+/+), additional sound (-/-)
C : HR : 92 x/mnt BP : 180/90 mmHg
D : GCS E4V5M6, equal width pupil (3 mm/3 mm), light
reflexes (+/+), lateralization (-)
E : T : 36,3 °C
Secondary Survey
Head : no abnormality
Eyes : no abnormality
Nose : no abnormality
Mouth : no abnormality

Ear : no abnormality
Neck : no abnormality
Chest : no abnormality
Abdomen : no abnormality
Extremities : Look at localized status
Localized Status
Right Thigh Region
L : Skin Intact (+), swelling (+), deformity
shortening (+), external rotation (+)
F : NVD (-), Leg length discrepancy 2cm
M: ROM Hip and knee limited due to pain
LLD D S
Apparent Length 84 86
True Length 76 78
Anatomical length 41 43
1st Assesment :
CF of Right Femur (ICD X S72.3)
Hypertension grade II
Geriatric

1st Plan :
IVFD. RL 20 dpm
Ketorolac inj 30 mg/8hr
Routine Blood Examination
Chest X-ray
Right Femur X-ray
Pelvic X-ray
AO Classification
2nd Assesment :
CF of 1/3 Distal Right Shaft Femur Spiral Type AO 32-A1 (ICD X
S72.302A)
Hypertension grade II (ICD X I16.0)
Geriatric (ICD X R41.81)
Porotic Bone (ICD X M81.0)

2nd Plan :
Orthopedic
Immobilization with skin traction
ORIF Femur Elective (Locking Plate)
Consult to Internal Medicine Department Sub Geriatric
Arrival Time 01.30
Triage Time 01.35
Surgery Dept. Time 01.45
Laboratorium Time 01.50 - 03.00
Radiology Time 02.00 – 02.45
Diagnosa Time 03.15
Inward 04.00
TERIMAKASIH

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