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Published byErica O’Neal’ Modified over 9 years ago
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Orthopedic & Traumatology Paper-less Status Outline
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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: 123456 Medical Record Number: 123456
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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.
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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)
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Medicinal History (including drug(s) that consummated right now) Drug nameDosageTime 1. Captopril12.5 mgThree times in a day 2. …………………………………………………………………… 3. …………………………………………………………………… 4. …………………………………………………………………… 5. ……………………………………………………………………
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Family History Hypertension Hypertension Diabetes Mellitus Heart disease Asthma Others……………………………………
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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)
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Vital Signs General condition : Good Moderate Moderate Weak Poor Nutrient : Good Good Moderate Poor Glasgow Coma Scale : E4M6V5 (Total: 15)
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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
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Prehospital Information Dates of events : 2/10/2015 Time: 16.20 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…………………………………………………………………...
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Prehospital Information (continued) Fall…….meter(s) from: Tree Building Others………………………………………… Gun shot Stab wound Crushed wound Burns Others…………………………………………
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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: ……………………………………
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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: ……………………………………………..
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Prehospital Action C-spine protection : No No Yes………………………. Airway device : No No Yes………………………. IV line : No No Yes………………………. Medications : No No Yes………………………. Others :…………………….
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PRIMARY SURVEY (16.55) A. Airway Free Free Obstructed Trachea in the middle : Yes Yes No Resuscitation :…………………………….. Re-evaluation :……………………………..
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PRIMARY SURVEY (16.55) B. Breathing Symmetry of chest : Yes Yes No Dyspneu : Yes No No Respiration : 20 x/minute Crepitation : Yes No No
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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
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PRIMARY SURVEY (16.55) O2 saturation : 98 % Nasal canula Nasal canula Non-rebreathing mask Others…………………………………………… At room temperature:………………. Assessment :…………………………………… Resuscitation :…………………………………. Re-evaluation :………………………………….
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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
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PRIMARY SURVEY (16.55) Skin description : Normal Normal Dry Moist/wet Assessment :……….………………………….. Resuscitation :………………………………….. Re-evaluation :………..………………………..
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PRIMARY SURVEY (16.55) D. Disability Alert Alert Response to Verbal Response to Pain Unresponsive Glasgow Coma Scale : 15, E4M6V5
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PRIMARY SURVEY (16.55) E. Exposure ……………………………………………………………………… ….……………………
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TRAUMA SCORE A. Respiration frequency : 10-254 25-353 >352 <101 00 B. Respiratory effort : Normal1 Shallow0
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TRAUMA SCORE (continued) C. Blood pressure >89 mmHg4 70-89 mmHg3 50-69 mmHg2 1-49 mmHg1 00 D. Capillary Refill < 2 second2 > 2 second1 None0
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TRAUMA SCORE (continued) E. Glasgow Coma Score (GCS) 14-155 11-134 8-103 5-72 3-41 TOTAL TRAUMA SCORE (A+B+C+D+E) : ……………
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PUPIL ASSESSMENT RightLeft Size (mm) Fast Constriction Slow Dilatation None
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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”
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CLINICAL FINDINGS (17.45)
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LABORATORY FINDINGS WBC: 15.400/ ul WBC: 15.400/ ul RBC: 5.000.000/ ul RBC: 5.000.000/ ul HBG: 14.7 g/dl HBG: 14.7 g/dl HCT : 43 % HCT : 43 % PLT: 233.000/mm3 PLT: 233.000/mm3 CT: 7’30’’ CT: 7’30’’ BT: 2’30’’ BT: 2’30’’ HBsAg: Non reactive HBsAg: Non reactive
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RADIOLOGIC FINDINGS (17.50)
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DIAGNOSIS Closed fracture right distal radius Closed fracture right distal radius (AO class 23-B1 IC1 MT1 NV1) Hypertension Grade I Hypertension Grade I
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INITIAL MANAGEMENT IVFD RL IVFD RL Analgesic Analgesic Report to Orthopaedic senior, advice: Report to Orthopaedic senior, advice: Apply volar slab below elbow
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OPERATION REPORT 1. Patient lay supine in General Anaesthesia 2. …………………… 3. …………………… 4. …………………… 5. ………………….. 6. ………………….. 7. …………………… 8. ……………………
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POST OPERATIVE
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POST OPERATIVE MANAGEMENT IVFD RL IVFD RL Analgesic Analgesic Antibiotic Antibiotic Position Position Etc. Etc.
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VISITE SOAP SOAP Subjective: Subjective: Objective: Objective: Assessment: Assessment: Planning: Planning:
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RESUME ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ……………………………………………………………………… ………………………………………………………………………
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