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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
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
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