status bedah orthopaedi

4

Click here to load reader

Upload: ardyana-prastara

Post on 15-Feb-2018

219 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Status Bedah Orthopaedi

7/23/2019 Status Bedah Orthopaedi

http://slidepdf.com/reader/full/status-bedah-orthopaedi 1/4

LAB/ SMF ILMU BEDAH ORTHOPAEDI

FK UWK SURABAYA

 ___________________________________________________  dr. Sigid Djuniawan, spB

 No register pasien :

I. IDENTITAS PASIEN MRS Tgl :

---------------------------

 Nama : ------------------------------------- L/P

Umur : ------------------------------------------

Alamat : ------------------------------------------

Tempat lair : ------------------------------------------

Su!u "angsa/ Agama : ------------------------------------------

Pe!er#aan : -----------------------------------------

Suami/istri : ------------------------------------------

II. ANAMNESA

$. %eluan Utama : (pain,deformity,swelling,lost of movement)

&. 'un(amental I )Ri*a+at Pen+a!it Se!arang, :

- lokasi, kualitas, kuantitas, onset, keadaan yang memperingan/memperberat, gejala penyerta

- mekanisme injury

. 'un(amental II ) Ri*a+at Pen+a!it Daulu / Ri*a+at alergi/ Ri*a+at Pengo"atan

se"elumn+a osteoporosis, :

Page 2: Status Bedah Orthopaedi

7/23/2019 Status Bedah Orthopaedi

http://slidepdf.com/reader/full/status-bedah-orthopaedi 2/4

. 'un(amental III ) Ri*a+at !eseatan !eluarga, :

0. 'un(amental I1 ) Ri*a+at sosial, :

III. PEMERI%SAAN 'ISI% 

$. %ea(aan !eseatan umum :

  1ital sign : Tensi : -------- Na(i : -------- RR : -------- temp a!sila/re!tal : -----

  23S : E ___ 1 ___ M ____ 

&. Pemeri!saan 'isi! Umum

%epala 4 Leer :

Cervial spine, neurology

Tora!s 4 %ar(io5as!ular :

!"orakal # $umbal, neurology

A"(omen 4 Pel5i6 4 Inguinal :

 %elvi and &ip, lengt" s"ortening 

Urogenital :

Anal 4Perianal :

E!stremitas Atas 4 A7illa :

Status vaskuler ' neurologis

E!stremitas 8a*a :Status vaskuler ' neurologis

. Status Lo!alis/ 9rgan :

Loo! )s!in sapeposition, :

 %embengkakan, deformitas (angulasi,rotasi,pemendekan),perlukaan kulit 

'eel )s!insot tissue"one, :

 yeri lokal, pulsasi,sensibilitas

Mo5e )a6ti5epassi5epo*er, :

Page 3: Status Bedah Orthopaedi

7/23/2019 Status Bedah Orthopaedi

http://slidepdf.com/reader/full/status-bedah-orthopaedi 3/4

 repitasi, false movement 

Joint )R9M : (egree o le!si/e!stensi a"(u!si/a((u!si internal

rotation/e!sternal rotation pronation/supination 6ir6um(u6tion, :

Deformity )5arus/5algus !+posis an( lor(osis s6oliosis i7e( (eormit+,

Tumor )si;esitesapeten(erness e(ge6onsisten6+ mo"ilit+,

I1. RESUME

$. Resume Anamnesa :

&. Resume Pemeri!saan 'isi! :

1. DIA2N9SA %ER<A / DIA2N9SA 8ANDIN2

$. Diagnosa Utama :

'ra!tur )lo!asie!stensi !onigurasiu"ungan ragmen ra!tur u"ungan

ra!tur (engan ling!ungan !ompli!asi

Dislo!asi

&. Diagnosa Pen+ulit :

. Diagnosa Pen+erta :

1I. USULAN PEMERI%SAAN PENUN<AN2 DIA2N9SA

$. La"oratorium :

&. Ra(iologi :

  *!wo+ iew,"anges,e-tremity and joint 

. 8iopsi / PA =

Page 4: Status Bedah Orthopaedi

7/23/2019 Status Bedah Orthopaedi

http://slidepdf.com/reader/full/status-bedah-orthopaedi 4/4

. Lain-lain :

1II. ANALISA DIA2N9SA 8ANDIN2 )resume "er(asar teori/!ulia/!epusta!aan,

$. Anamnesa :

&. Pemeri!saan 'isi! =

. Pemeri!saanPenun#ang (iagnosa :

1III. USULAN TERAPI

Reposisi )ter"u!a/tertutup, imo"ilisasirea"ilitasi

I>. PR92N9SA