CASE REPORTFryday, 22nd , 2016

Team on dutydr. Nazir (Jaga 1)dr. Tommy Rivelino (Jaga 2)dr. Raja Raharja (Jaga 3)dr. Aswad Affandi (Jaga 3)dr. Arfan Asmadi (Jaga 4)dr. Ike Yoganita (Jaga 5)dr. Syahmardani (Jaga 5)dr. Jufrialdi (Jaga 6)dr. Arie Nasir (Jaga 6)

Date/hour patient came to

ER

Examination hour

Laboratory Examination

Radiology Examination

Hour of Diagnostics

Date/ hour patient out from ER

DPJP

Send Result Send Result

April 22nd

WIB10.00

10.00 WIB 10.30

WIB

11.30 WIB

10.30

WIB

11.00 WIB

11.00 WIB 21.00 WIB to OR

Dr. Azharuddin,Sp.OT.K.Spine

Patient Identity • Name : Muhajir• Age : 27 years old• Sex : Male• Address : Desa Lamsinye Kec. Darussalam Kab. Aceh Besar• CM : 1087885• HP : 082361417779• Admission Time : 14.30 AM

Chief Complaint: Pain and difficulty to move of the right thumb Present illness historyThe 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 surveyHead and neck in normal limitThorax in normal limitAbdominal in normal limitUpper extremityL/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 : 14.7 gr/dl• White Blood Count : 6.500 mg %• Platelets : 285.000 /ul• Hematocrit : 43 %• CT/BT : 7’/2’

Radiology examination

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 diagnoseOpen fracture dislocation of the distal phalanx of the right thumb

Follow upDate S O A PApril 25th 2016POD III

Pain (-) General Condition : goodBP : 130/80 mmHgPulse : 80x/minuteRR : 20x/minute L/S at the right thumbL : Gauze dry (+), necrotic (-) K-wire (+)F : Pain (-), NVD (-)M : ROM limited   

 Post debridement + K-wireOpen fracture dislocation of the distal phalanx of the right thumb

Out of clinic