Download - Jaga Siang, Senin 15 Juni 2015
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Jaga SiangSenin, 15 Juni 2015
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Identitas Pasien
Nama : Mariani HJK : PerempuanUmur : 60 tahunAlamat : Ds. Tutong, Bandar BaruPekerjaan : IRTStatus : MenikahSuku : AcehJam MRS : 15.45 WIBNo CM : 006001
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K.Utama : Nyeri Kepala
K.Tambahan : Luka robek di bibir, muntah, pusing
RPS : Pasien datang dengan keluhan nyeri dikepala setelah KLL. Kejadian ini dialami pasien ±20 menit SMRS. Pasien juga mengeluh nyeri saat menggerakkan jari kelingking sebelah kanan dan ada luka robek di bibir. Riwayat pingsan (-), riw.pusing (+), riw.muntah (+).
RPD : -RPO : -
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Mekanisme Trauma : Pasien dibonceng dengan sepeda motor, tiba-tiba rok pasien masuk kedalam jari-jari sepeda motor, sehingga pasien terjatuh dalam posisi tengkurap dan kepala pasien membentur aspal.
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Primary Survey
A : ClearB : Spontan, paten RR : 22 x/menitC : TD : 110/80 mmHg ND : 80 x/menitD : GCS : E4V5M6 =15 (Composmentis)E : 35,2ᴼC
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Secondary Survey
- Regio FrontalLook : Vulnus ekscoriatum dan bengkak Ɵ6x6 cmFeel : Nyeri (+)Move : ROM tak terbatas
- Regio LabialisLook : Vulnus Laceratum Ɵ 1x0,1cmFeel : Nyeri (+), Perdarahan (+)Move : ROM tak terbatas
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- Regio Manus (D)Look : Vulnus Ekscoriatum a/r palmar manus (D) Ɵ 1x1cm, bengkak digiti V (D)
Feel : Nyeri (+)
Move : ROM terbatas
NVD : CRT <2 detikAkral : hangatSensasi : terasa
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Diagnosa sementara : Cidera kepala ringan
Pemeriksaan penunjang : - Foto Schedel AP/Lat- Foto Cevical AP/Lat- Foto Manus (D)
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Diagnosa kerja : Cidera kepala ringan + fraktur digiti V phalanx proximal manus (D) tertutup + M.V Ekscoriatum
Tindakan : - wound care - Cervical Collar
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Terapi : - O2 : 4 L/i - IVFD Asering 20 gtt/i - inj. Citicoline 500 mg/12 jam - PCT fls /8 jam - inj. Ondansetron amp/12 jam - inj. Ranitidin amp/12 jam - inj. Cefotaxine 1 gr/12 jam - Betahistin tab 3x1
Keterangan : Rawat R.Saraf