laporan jaga 16-3-2015
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LAPORAN JAGASenin, 16 Maret 2015
Residen : dr. RizkyCoass : Ajeng, Gresia, Putri, Sheilla
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Resume pasien
• Rawat jalan : 3• Rawat inap : 0• Operasi : 0
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Identitas Pasien
Nn E, 23 tahun
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KU
Luka terbuka yang menghitam pada sela jari 2 dan 3 kaki kiri sejak 4 SMRS.
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Primary Survey
• A : clear• B : spontan, RR : 24 x/mnt• C : TD : 90/60 mmHg
N : 87 x/mnt•D : GCS E4V5M6
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Secondary Survey
• RPS– Timbul lentingan warna putih pada sela jari II-III
kaki kiri sejak 4 hari SMRS. Sejak 3 hari SMRS luka menjadi terbuka dan berwarna hitam kemerahan. Tidak ada demam.
• RPD : • DM - , alergi -, pengobatan : menggunakan kapur sirih
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Status Generalis
• Kepala : normocephal, simetris• Mata: CA(-/-) SI (-/-)• Thoraks : – Paru : vesikuler, Rh (-/-), Wh (-/-)– Jantung : BJ I-II murni reg m (-), g (-)
• Abdomen : datar, supel, BU (+)• Ektremitas : oedem (-),sianosis (-), akral
hangat
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Status LokalisRegio interdigiti II-III pedis sinistra• Look : tampak abses hiperemis (+) jaringan nekrotik (+),
fluktuasi (+).• Feel : nyeri tekan (+)• Move : tidak dapat digerakkan
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Diagnosa
• Abses Interdigiti 2-3 Pedis Sinistra
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Planning
• Debridement• Cefixime 2 x 200mg PO• Metronidazol 3 x500mg PO• Asam Mefenamat 3 x 500mg PO• Ranitidin 2 x 150 mg PO • Rawat jalan• Edukasi perawatan luka pada pasien
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TERIMA KASIH