Orthopedic & Traumatology Paper-less Status Outline

IDENTITY Name: X Name: X Place/Date of Birth: Makassar, July 10 th, 1975 Place/Date of Birth: Makassar, July 10 th, 1975 Age/Sex: 40 years old / Male Age/Sex: 40 years old / Male Job: Office Boy Job: Office Boy Admission Date/Time: October 2 nd, 2015 / 16:50 Admission Date/Time: October 2 nd, 2015 / 16:50 Medical Record Number: Medical Record Number:

Anamnesis (16.50) Chief Complain: Pain at right wrist Chief Complain: Pain at right wrist Recent Medical History: Recent Medical History: Suffered since 30 minutes before admitted to Wahidin General Hospital. Suffered since 30 minutes before admitted to Wahidin General Hospital. Patient was riding a motorcycle and was hit by another motorcycle. Patient tried to break the fall using her right arm. Patient was riding a motorcycle and was hit by another motorcycle. Patient tried to break the fall using her right arm. History of loss of consciousness (-), Vomitting (-) nausea (-) History of loss of consciousness (-), Vomitting (-) nausea (-) No prior treatment. No prior treatment.

Past Medical History: Past Medical History: Hypertension Hypertension  Liver  Diabetes Mellitus  Kidney  Coronary Heart Disease  Tuberculosa Asthma Asthma  Cigarette  Stroke  Alcoholic  Others…………………………………………. Hospitalization History: Hospitalization History: No No  Yes, When…………………Where…………………………… Diagnosis……………………………… Anamnesis (16.50)

Medicinal History (including drug(s) that consummated right now) Drug nameDosageTime 1. Captopril12.5 mgThree times in a day 2. …………………………………………………………………… 3. …………………………………………………………………… 4. …………………………………………………………………… 5. ……………………………………………………………………

Family History Hypertension Hypertension  Diabetes Mellitus  Heart disease  Asthma  Others……………………………………

Pain Assessment PAIN : Yes Yes  No Onset : Acute Acute  Chronic Trigger :……………………………………………………. Pain description : Sharp Pain Pain location : Right Wrist Duration :………..………………………………………….. Frequency :………….………………………………………... Pain scale : 7 out of 10 (Method : NRS/BPS/FLACC/NIPS)

Vital Signs General condition :  Good Moderate Moderate  Weak  Poor Nutrient : Good Good  Moderate  Poor Glasgow Coma Scale : E4M6V5 (Total: 15)

Vital Signs (continued) Resuscitation :  Yes No No Body weight : 70 kg Body height : 169 cm Blood pressure : 150/90 mmHg Heart rate : 100 x/minute Respiration : 20 x/minute Axilla/Rectal temperature : 36.7 ° C

Prehospital Information Dates of events : 2/10/2015 Time: Place: BTP Mechanism of Injury:  Motor vehicular Accident:  Car :  Driver  Passenger  Wearing safety belt :  Yes  No Motorcycle : Motorcycle : Driver Driver  Passenger  Using helmet : Yes Yes  No  Pedestrian, hit by :  Car  Motorcycle  Others…………………………………………………………………...

Prehospital Information (continued)  Fall…….meter(s) from:  Tree  Building  Others…………………………………………  Gun shot  Stab wound  Crushed wound  Burns  Others…………………………………………

AMPLE History Allergy : No No  Yes, Specify: ……………………………… Medication :  No Yes, Specify: Captopril 12,5 mg TID Yes, Specify: Captopril 12,5 mg TID Comorbid disease :  No Yes, Specify: Hypertension Yes, Specify: Hypertension Last meal :  No Yes, Time: 8 hours ago Yes, Time: 8 hours ago NAPZA : No No  Yes, Specify: ……………………………………

AMPLE History (continued) Last injection of Anti Tetanus : No No  Yes, Specify: …………………. Pregnancy (if male, skip to next item) :  No  Yes, Age of pregnancy ……………month Last menstruation period:.……………………………………………. Another Events Related: ……………………………………………..

Prehospital Action C-spine protection : No No  Yes………………………. Airway device : No No  Yes………………………. IV line : No No  Yes………………………. Medications : No No  Yes………………………. Others :…………………….

PRIMARY SURVEY (16.55) A. Airway Free Free  Obstructed Trachea in the middle : Yes Yes  No Resuscitation :…………………………….. Re-evaluation :……………………………..

PRIMARY SURVEY (16.55) B. Breathing Symmetry of chest : Yes Yes  No Dyspneu :  Yes No No Respiration : 20 x/minute Crepitation :  Yes No No

PRIMARY SURVEY (16.55) Breath sounds (Ausculatation) : Right : Present : Present : Clear Clear  Decrease  Ronchi  Wheezing  Absent Left : Present : Present : Clear Clear  Decrease  Ronchi  Wheezing  Absent

PRIMARY SURVEY (16.55) O2 saturation : 98 % Nasal canula Nasal canula  Non-rebreathing mask  Others…………………………………………… At room temperature:………………. Assessment :…………………………………… Resuscitation :…………………………………. Re-evaluation :………………………………….

PRIMARY SURVEY (16.55) C. Circulation Blood presssure : 150/90 mmHg Pulse rate: 100 x/minute Strong Strong  Weak Regular Regular  Irregular Axilla temperature : 36.7°C Rectal temperature:……………………C Skin temperature : Warm Warm  Hot  Cold

PRIMARY SURVEY (16.55) Skin description : Normal Normal  Dry  Moist/wet Assessment :……….………………………….. Resuscitation :………………………………….. Re-evaluation :………..………………………..

PRIMARY SURVEY (16.55) D. Disability Alert Alert  Response to Verbal  Response to Pain  Unresponsive Glasgow Coma Scale : 15, E4M6V5

PRIMARY SURVEY (16.55) E. Exposure ……………………………………………………………………… ….……………………

TRAUMA SCORE A. Respiration frequency :    >352  <101  00 B. Respiratory effort :  Normal1  Shallow0

TRAUMA SCORE (continued) C. Blood pressure  >89 mmHg4  mmHg3  mmHg2  1-49 mmHg1  00 D. Capillary Refill  < 2 second2  > 2 second1  None0

TRAUMA SCORE (continued) E. Glasgow Coma Score (GCS)     5-72  3-41 TOTAL TRAUMA SCORE (A+B+C+D+E) : ……………

PUPIL ASSESSMENT RightLeft Size (mm) Fast Constriction Slow Dilatation None

SECONDARY SURVEY (17.05) Right Wrist Region Look:Deformity (+), swelling (+), hematoma (-), wound (-) Feel:Tenderness (+) Move:Active and passive motions of the elbow are within normal limits Active and passive motions of the wrist are limited due to pain NVD:Good sensibility, radial and ulnar artery pulses are palpable, CRT <2”

CLINICAL FINDINGS (17.45)

LABORATORY FINDINGS WBC: / ul WBC: / ul RBC: / ul RBC: / ul HBG: 14.7 g/dl HBG: 14.7 g/dl HCT : 43 % HCT : 43 % PLT: /mm3 PLT: /mm3 CT: 7’30’’ CT: 7’30’’ BT: 2’30’’ BT: 2’30’’ HBsAg: Non reactive HBsAg: Non reactive

RADIOLOGIC FINDINGS (17.50)

DIAGNOSIS Closed fracture right distal radius Closed fracture right distal radius (AO class 23-B1 IC1 MT1 NV1) Hypertension Grade I Hypertension Grade I

INITIAL MANAGEMENT IVFD RL IVFD RL Analgesic Analgesic Report to Orthopaedic senior, advice: Report to Orthopaedic senior, advice:  Apply volar slab below elbow

OPERATION REPORT 1. Patient lay supine in General Anaesthesia 2. …………………… 3. …………………… 4. …………………… 5. ………………….. 6. ………………….. 7. …………………… 8. ……………………

POST OPERATIVE

POST OPERATIVE MANAGEMENT IVFD RL IVFD RL Analgesic Analgesic Antibiotic Antibiotic Position Position Etc. Etc.

VISITE SOAP SOAP Subjective: Subjective: Objective: Objective: Assessment: Assessment: Planning: Planning:

RESUME ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ………………………………………………………………………