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    Post Test Remove Implant

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    akbar
    1. This document summarizes the medical records of a 56-year-old male patient who underwent removal of a plate and screws in his right distal radius that were implanted 1 year ago. 2. Laboratory tests, including blood tests and coagulation studies, were conducted and found to be normal. X-rays of the right wrist showed union of the distal radius fracture. 3. The patient underwent an uncomplicated procedure under general anesthesia to remove the plate and screws from his healed right distal radius fracture. Post-operative recovery was satisfactory.

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    Post Test Remove Implant

    Uploaded by

    akbar
    24 views14 pages
    1. This document summarizes the medical records of a 56-year-old male patient who underwent removal of a plate and screws in his right distal radius that were implanted 1 year ago. 2. Laboratory tests, including blood tests and coagulation studies, were conducted and found to be normal. X-rays of the right wrist showed union of the distal radius fracture. 3. The patient underwent an uncomplicated procedure under general anesthesia to remove the plate and screws from his healed right distal radius fracture. Post-operative recovery was satisfactory.

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    Post test Remove implant

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    Post test Remove implant

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    1. This document summarizes the medical records of a 56-year-old male patient who underwent removal of a plate and screws in his right distal radius that were implanted 1 year ago. 2. Laboratory tests, including blood tests and coagulation studies, were conducted and found to be normal. X-rays of the right wrist showed union of the distal radius fracture. 3. The patient underwent an uncomplicated procedure under general anesthesia to remove the plate and screws from his healed right distal radius fracture. Post-operative recovery was satisfactory.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    24 views14 pages

    Post Test Remove Implant

    Uploaded by

    akbar
    1. This document summarizes the medical records of a 56-year-old male patient who underwent removal of a plate and screws in his right distal radius that were implanted 1 year ago. 2. Laboratory tests, including blood tests and coagulation studies, were conducted and found to be normal. X-rays of the right wrist showed union of the distal radius fracture. 3. The patient underwent an uncomplicated procedure under general anesthesia to remove the plate and screws from his healed right distal radius fracture. Post-operative recovery was satisfactory.

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    You are on page 1of 14

    POST TEST

    UNION DISTAL RADIUS DEXTRA

    Arranged by :
    MELIANI

    Mentor :
    Dr. dr. Adrian Khu, Sp. OT, FICS

    Kepaniteraan Klinik Senior Bagian Ilmu Bedah Orthopaedic


    RS Royal Prima Medan
    PATIENT STATUS
    Room Number : 706
    Day / Date of Entry Room: Desember 28, 2018
    Physician in charge: dr. Muhammad Rizal Renaldi, Sp. OT

    PATIENT IDENTITY:
    Name : Tn. A
    Number Of MR : 064882
    Age : 56 years old
    Gender : Male
    Religion : Islam
    ANAMNESA

    Main complaint : The patient came to the polyclinic Royal Prima


    Hospital to complaints for post ORIF 1 years ago
    and wants to release Pen

    Previous Disease History : -


    VITAL SIGN
    • General Conditions : Good
    • Sensorium / GCS : Compos Mentis / 15
    • Pulse : 92 x / i
    • Respiration : 20 x / i
    • Temperature : 37º C

    Primary Survey
    • A : Airway clear, no airway obstruction
    • B : RR : 20 x / I
    • C : HR: 92 x / i, regular
    • D : GCS : 15 (E4V5M6)
    • E : T: 37 ºC
    GENERAL STATUS
    • Head : Normocephali
    • Eyes : Pupil: Isokor (+ / +)
    • Sclera : Ikterik (- / -)
    • Conjunctiva : Anemis (- / -)
    • Light reflex : (+ / +)
    • Ear : Normal shape, secretions (-)
    • Nose : Normal shape, hyperemic konka (-), septal deviation (-)
    • Mouth : Normal shape, cyanosis (-)
    • Neck : Lymph nodes enlargement (-)

    Thorax (Lungs)
    • Inspection : fusiform symmetrical chest shape, rib interception (-)
    • Palpation: right = left stem fremitus
    • Percussion : sonor
    • Auscultation: Vesikuler
    Heart
    • Inspection : ictus cordis is not visible
    • Palpation: ictus cordis palpable
    • Percussion : dim, right and left heart limits cannot be assessed
    • Auscultation: S1S2 normal, Gallop (-), Murmur (-)

    Abdomen
    • Inspection : symmetrical
    • Palpation: soepel, tenderness (-), hepatomegaly (-), splenomegaly (-)
    • Percussion : timpani
    • Auscultation: peristalsis (+) normal impression

    Extremity
    • Superior : warm + / +, pain -/+, edema -/-
    •
    Orthopedic examination
    Look
    The patient's condition is good
    Feel
    Pain (-)
    Move
    No pain when moved

    Temporary Diagnosis:
    Union (L) Distal Radius with plate and screw

    Recommendation:
    - Laboratory examination (complete blood, clotting time, bleeding time)
    Laboratory examination
    HEMATOLOGI
    No. Pemeriksaan Hasil Satuan Normal
    1 Hemoglobin 13.9 g/dl 12.5 – 14.5
    2 Leukosit 8.91 /mm3 5000 – 11000

    3 LajuEndapDarah 10 mm/jam 0 – 20

    4 Trombosit 334 /mm3 150000 – 450000

    5 Hematocrit 42.5 % 30.5 – 45.0


    6 Eritrosit 4.70 10^6/mm3 3.50 – 5.50
    7 MCV 90.4 fL 75.0 – 95.0
    8 MCH 31.8 Pg 27.0 – 31.0
    9 MCHC 35.2 g/dl 33.0 – 37.0
    10 RDW 14.3 % 11.50 – 14.50
    11 PDW 61.5 fL 12.0 – 53.0
    12 MPV 10.2 fL 6.50 – 9.50
    13 PCT 0.12 % 0.100 – 0.500
    14 HitungJenisLeukosit
    Eosinofil 2 % 1–3
    Basofil 0.5 % 0–1
    Monosit 5.3 % 2–8
    Neutrofil 58.5 % 50 – 70
    Limfosit 27.7 % 20 – 40
    LUC 6 % 0–4
    COAGULATION

    NO Examination Result Unit Normal Method

    1 Bleeding time 3’15’’ Menit 1-5 -

    2 Blood clotting time 7’30’’ Menit 5-15 -


    RADIOLOGI

    Radiology : Right Wrist Joint AP/Lat


    Work Diagnosis
    Remove Implant Union (R) Distal Radius with plate and screw

    Planning
    • RL IVFD fluids 20 gtt / i macro
    • The patient is asked to fast before surgery
    • Ceftriaxone 1gr/ 12 hours
    • Ketorolac Inj 1 amp / 8 hours IV
    • Ranitidine 1 amp / 12 hours IV

    Action:
    1. Supine position under general anesthesia
    2. Disinfectants and drapping procedures
    3. Incision and identification of fractures
    4. Remove implant
    5. Wash the wound and cover the wound
    Post Surgery
    Postoperative Assessment :
    General condition : satisfying
    Awareness level : awake
    Breath : free
    Respiratory : spontaneous

    Education:
    Do not maneuver which can inhibit wound healing and
    Schedule a re-consultation to monitor the results of the action.
    THANK YOU

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