CASE REPORT

Fryday, 22nd , 2016

Team on duty
dr. Nazir
dr. Tommy Rivelino
dr. Raja Raharja
dr. Aswad Affandi
dr. Arfan Asmadi
dr. Ike Yoganita
dr. Syahmardani
dr. Jufrialdi
dr. Arie Nasir
Date/hour
patient
came to
ER

Examination
hour

April
22nd
WIB
10.00

10.00 WIB

Laboratory
Examination
Send

Patient Identity
Name
Age
Sex
Address
CM
HP
Admission Time

(Jaga 1)
(Jaga 2)
(Jaga 3)
(Jaga 3)
(Jaga 4)
(Jaga 5)
(Jaga 5)
(Jaga 6)
(Jaga 6)

Result

10.30
WIB

11.30
WIB

Radiology
Examination
Send
10.30
WIB

Result
11.00
WIB

Hour of
Diagnostics

Date/ hour
patient out from
ER

11.00 WIB 21.00 WIB to OR

DPJP

Dr.
Azharuddin,Sp
.OT.K.Spine

: Muhajir
: 27 years old
: Male
: Desa Lamsinye Kec. Darussalam Kab. Aceh Besar
: 1087885
: 082361417779
: 14.30 AM

Chief Complaint:
Pain and difficulty to move of the right thumb
Present illness history
The patient came to RSUZA Emergency room with a chief complaint pain and difficulty to move
the right thumb since 1 hour ago. Initially, patient was worked in the garden with the cutting
machine. And than the machine cut his thumb

Physical examination

 A
: Clear
B
: Spontaneous, 20 breaths/min
C
: BP : 130/80 mmHg, HR : 90 beats/min
D
: GCS E4M6V5: 15
E
:
L/S at the right thumb
L
: Deformity (+), lacerated wound (+) size 1x1 cm bone expose (+), t
tendon expose (+)
F
: Pain (+), NVD (-)
M
: ROM limited

Secondary survey
Head and neck
in normal limit
Thorax
in normal limit
Abdominal
in normal limit
Upper extremity
L/S at the right thumb
L
: Deformity (+), lacerated wound (+) size 1x1 cm, bone expose (+),
tendon expose (+)
F
: Pain (+), NVD (-)
M
: ROM limited
Lower extremity
in normal limit
VAS : Moderate
Assessment:
Open fracture of the right tumb
Management
Stop oral intake
IVFD RL 20 drips/min
Cefazoline inj 1 gr
Ketorolac Inj 30 mg
Tetagam Inj 250 IU
Laboratory examination
Radiology examination
Laboratory examination
Haemoglobin
White Blood Count
Platelets
Hematocrit
CT/BT
Radiology examination

: 14.7 gr/dl
: 6.500 mg %
: 285.000 /ul
: 43 %
: 7/2

Right manus Ap/oblique:

Discontinuity of the distal phalanx of the right thumb
Diagnose
Open fracture dislocation of the distal phalanx of the right thumb
Consult to orthopedic surgery division:
Debridement + K-wire emergency
Operative report
Perfomed debridement with pavodine iodine + normal saline + peroxide
Perfomed reposition and fixation with K-wire
Post operative diagnose
Open fracture dislocation of the distal phalanx of the right thumb
Follow up
Date
April 25th
2016
POD III

S
Pain (-)

O
General Condition : good
BP : 130/80 mmHg
Pulse : 80x/minute
RR
: 20x/minute
L/S at the right thumb
L : Gauze dry (+), necrotic
(-) K-wire (+)
F : Pain (-), NVD (-)
M : ROM limited

A
P
Post debridement + K- Out of clinic
wire
Open fracture dislocation
of the distal phalanx of
the right thumb