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REPORT

January, 10th 2016

Agustian Deny

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1. Ulkus

dekubitus

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Primary SurveyO Airay ! "lear

O #reathing ! "lear, rate! 2$%&min

O "ir'ulati(n ! "lear, )ulse rate!*+%&min, regular, #P! 10&*0 mm-g

O Disability! Para)arese

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Se'(ndary survey

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dentityO /ame! n.

O Age ! years (ld

O 3eligi(n ! slamO Address ! 2+ O't(ber street

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Present llnessPasien #A# terus5menerus se7ak 1 hari S83S, #A#

lembek 9:;, arna agak kehitaman se)erti k()i 9:;,

lendir 9:;.

Pasien merasa makin lemah 2 hari S83S, demam9:; hilang timbul, mual 9:;, muntah 95;, na4su makan

turun 9:;, )using 9:;

3iayat lum)uh kedua kaki se7ak 10 tahun S83S,

#A< sering ng(m)(l, #A# kurang lebih %&hari,

namun se7ak 1 hari yang lalu #A# %.

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Present llness 92;O 3iayat adanya bisul di dekat dubur

se7ak 2 bulang yang lalu, )asien tidak

)ernah dibaa ber(bat, bisul )e'ah danbernanah

O 3iayat sering nyeri ulu hati 95;, - 95;,D8 95;

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=ital SignO "(n'iussness ! "(m)(s 8entis, "S

1

O Pulse ! +0 % & minuteO 3es)irat(ry 3ate ! 2$ % & minute

O #P ! 10&*0

Oem)erature ! 6, O"

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Physi'al >%aminati(nseneral Status

O -ead ! /(rm('e)hal

O >yes ! "A 95&5;, S 95;O >/ ! in n(rmal range

O /e'k ! 95;

O "hest ! symmetri'al

O "(r ! S1, S2 8 95; 95;O Pulm( ! =#S 9:&:;, ?h 95&5;, 3h 95&5;

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Physi'al >%aminati(ns

92;O Abd(men !

o ns)e'ti(n ! @at

o Aus'ultati(n! #(el s(und 9:; n(rmal, metali' s(und

95;,o Per'uti(n ! tim)ani 9:;

o Pal)ati(n ! S(e)el, tenderness 9:; lumbar5umbilikus5lumbar. >)igastrium, mus'ular de4ense 95;, "=A 95&5;,ball(tement 95&5;

O Anal ! ul'us di )erianalO >%tremity ! arm 9:;, "3 2 se'(nds, edema 95;,

=> di genu anteri(r et )(steri(r, P(er $22

1111 2222

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B('alis status

O 3! am)ula re'ti nihil, t(nus nihil,mu'(sa sm((th, hands'((n! 4eses9:; bl((d 9:;

- enderness 9:;lumbar de%tra sinistraet umbilikus.

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Ceatures

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?(rking Diagn(sisO Ulkus dekubitus

O Para)arese

O nk(ntinensi uri et alvi

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Additi(nal >%aminati(nO "(m)lete #l((d "(unt 9Beu'('yte

1$,6 % 10&l, >ritr('yte ,+ % 1012&l ,

-gb 16,* g&dl, r(mb('yte 1 % 10

&l;O #l((d lu'(se ! 111 mg&dl

O Ureum! 6 mg&dl

O "reatinin! 1, mg&dl

O SO! 1 u&lO SP! 21 u&l

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reatmentO 8edi'ament(sa

O =CD 3B 20 t)m

O "e4tria%(ne % 1 gr 9=;O 3('er 1%1

O

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5 8ild head in7ury

5 3ib 4ra'ture

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Primary SurveyO Airay ! "lear

O #reathing ! "lear, rate! 20%&min

O "ir'ulati(n ! "lear, )ulse rate!+$%&min, regular, #P! 100&0 mm-g

O Disability! "he)al hemat(m : =>tem)(ral sinistra, => elb( sinistra

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dentityO /ame! 8r. S

O Age ! + years (ld

O 3eligi(n ! slamO ?(rk ! Carmer

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"hie4 "(m)laint/yeri dan luka )ada ke)ala sebelahkiri )(st

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Present llnessPasien datang dengan keluhan nyeri )adake)ala sebelah kiri disertai adanya bengkakdan luka le'et )(st ditabrak saat sedang

7alan kaki.

Pasien ditabrak dari sam)ing dan kemudian7atuh terbaring. )ingsan 95;, mual 9:;,muntah 9:; 2%, )erut kiri atas terbentur 9:;,terbentur )ada bagian dada 95;

Pasien 7uga mengeluh nyeri 9:; )ada )erutkiri atas dan tulang rusuk kiri baah.

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=ital SignO "(n'i(ussness! "8, "S >$8=6

O Pulse ! 6+ % & minute

O #P ! 100&*0 mm-gO 3es)irat(ry 3ate ! 20 % & minute

Oem)erature ! * O"

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Physi'al >%aminati(nseneral Status

O -ead ! /(rm('e)hal, hemat(m 9:; tem)(ral sinistra

O >yes ! "A 95&5;, S 95;

O >/ ! bleeding 95;O /e'k ! /( '(m)lainO "hest ! symmetri'al, "(r ! S1, S2 8 95; 95;

o ns)e'ti(n ! eu)nea

o Pal)ati(n ! tenderness )ada hemith(raks sinistra 9gake ;, iga teraba m(bile 9:;, kre)itasi 9:;, selling

95;o Per'uti(n ! s(n(r kedua la)ang )aru

o Aus'ultati(n! =#S 9:&:;, ?h 95&5;, 3h 95&5;

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O Abd(men !o ns)e'ti(n ! @at

o Aus'ultati(n! b(el s(und 9:;, metali's(und 95;

o Per'uti(n ! tim)ani 9:;o Pal)ati(n ! s(e)el, tenderness 9:; su)eri(r

lumbar sinistra. >)igastrium, mus'ularde4ense 95;, "=A 95&5;, ball(tement 95&5;

O >%tremity ! arm 9:;, "3 2 se'(nds,edema 95;, => 9:; elb( sinistra

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B('alis Status

- enderness 9:;lumbar sinistra.

-

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?(rking Diagn(sisO 8ild head in7ury

O #lunt trauma abd(minal

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Additi(nal >%aminati(n

O "(m)lete #l((d "(unt 9Beu'('yte

1$, % 10&l, >ritr('yte ,1* % 1012&l ,

-gb 12 g&dl, r(mb('yte 2*$ % 10&l;

O #l((d lu'(se ! 116 mg&dl

E 3ay

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E53ay

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reatment8edi'ament(sa!

O v4d 3B 20 t)m

O "4tria%(ne 2%1grO Pira'etam %1am)

O

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5 "(li' abd(men e.' sus).ureter(lithiasis

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Primary Survey

O Airay ! "lear

O #reathing ! S)(ntan, 1+%&minute

O "ir'ulati(n ! #P! 1$0&100 mm-g,Pulse! ++ %&minute, "3 2F

O Disability ! 5

O >vent ! 5

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Se'(ndary Surveydentity!

O /ama! n. A.S

O Umur ! 2 tahunO Peker7aan ! entara

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AnamnesisO

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>%aminati(n -ead t(

(eO -ead ! /(rm('e)hal

O >yes! Pu)il is('h(r 2mm&2mm, Bight 3e@e% 9:&:;

O >/ ! #leeding 95;, t(nsil 1&1

O /e'k ! n7ury 95;, Pain 95;O "hest! Pain 95;, Dis)nea 95;

O "(r ! S1,S2 regular, 895;, 95;

O Pulm( ! =#S 9:&:;, ?h 95&5;, 3h 95&5;

O Abd(men ! S(e)el, tenderness 95;, #(el s(und

9:; /.O -e)ar and Bien! /(rmal

O >%tremity! akral hangat 9:;, 'rt 2F

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B('al Status! 3egi( abd(men

- enderness 9:;, nyeriket(k 'va :&5 ,ball(tement 95&5;, )s(assign 95;, (bturat(r sign95;, mur)hy sign 95;,reb(und sign 95;

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?(rking diagn(sisO "(li' abd(men e.' sus).

ureter(lithiasis

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Additi(nal >%aminati(nO "(m)lete #l((d "(unt 9Beu'('yte

1, % 10D&l,, -gb 12, g&dl,

r(mb('yte 6 % 10D&l;O #l((d lu'(se ! 112 mg&dl

O Ureum! 2* mg&dl

O "reatinin! 1,0 mg&dl

O SO! 2$ u&lO SP! 0 u&l

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#/O E53ayO m)ressi(n!

O O)aGue '(n'rament 95;

O Air distributi(n in b(el seems n(rmal

O =ertebral alignment n(rmal,

(ste()hyte 95;

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reatmentO =CD 3B 20 t)m

O "e4tria%(ne 1 % 2 gr 9=;

O

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THANK YOU