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EMERGENCY ROOM
BAHTERAMAS GENERAL HOSPITAL
KENDARI
IDENTITY
Name : Mrs. HM
Age : 42 years old
Sex : Female
Address : Morini Village
Occupation : Housewife
Admission : March 26th 2019
Doctor in charge : dr. Mario Polo Wijaya, M.Kes , Sp.OT
Anamnesis (06.35)
Chief complain : Pain at the right wrist
History Taking
Suffered since ± 5 months ago before admission to the hospital. The
pain was radiated to upper arm. Pain was intermittent, increased by
supine or pronate forearm, decreased by rest.
Mechanism of trauma : : Patient was at the airport lifting up her luggage
with right hand but suddenly there was another people beside her also lifted
luggage and hit her right wrist.
History of Trauma
There was a dominant right hand
Vital Sign
BP : 110/80 mmHg
HR : 84x/minutes, regular, strong
RR : 22x/minutes regular, spontaneous, symetris
T : 36.5 ◦C / axillar
VAS : 5/10
PRESENT STATE
Right Wrist
Inspection: Deformity (-), swelling (+), hematoma (-),
wound (-)
Palpation : tenderness (+), crepitation (-)
ROM : active and passive movement of wrist
joint and elbow joint limited due to pain
NVD : good sensibility, radial artery pulsation
(+), CRT < 2 second.
CLINICAL FINDING
PLANNING
Differential Diagnosis :
- Fracture at Distal Radius
- Dislocation at Distal Radioulnar joint
MANAGEMENT
Pharmacological Non-Pharmacological
• IVFD
Rest
• Analgesic injection
• H2R antagonist injection Immobilization
Education