Ni Made Febri Supervisor : Letkol Ckm dr. Basuki Widodo, Sp.

OT

Identity

She lived at Ds. Bawang, RT 07 RW 14 Kel. Ngadirejo V, Salaman

Anamnesa
Chief complaints: The patient came to the Orthopaedic clinic with complaints that the right IV fingers can not be properly right into a straight after flexi in the last 1 month.

History of present illness: the right IV finger pain sometimes when move. Attacks usually occur in the morning until late afternoon, in the night is not come. Medical history first: 1 year ago had fallen and her fingers slightly curved, and was taken to Sangkal Putung. Family history of disease: hypertension (-), Diabetes Mellitus (-). Socio-Economic History: The state of patient socioeconomic well. Patients supported by ASKES, and treated in Ward Edelweis VIP class.

Vital Sign
Blood presurre

120/80 mmHg Pulse : 84x/ minute Temperature : 36 C Respiratory : 24 x/ minute

Physical Examination
HEAD Eye : CA -/- , SI -/ Pupil isocor : 2 milimetres Head Shape : Mesochepal THORAX
Cor : SI dan SII normal regular Pulmo : vesicular, ronkhi -/- , wheezing

-/-

ABDOMEN Inspection : Symmetrical, flat stomach, sikatrik (-) Auscultation Palpation off(-), no enlarged Percussion : Bowel (+) normal

: tenderness (-),pain liver and spleen palpable : Timpani

EXTREMITAS

DIGITI IV DEXTRA Look : do not look any deformity Feel : pain (-), edema (-), pulse (+) Movement : you hear a "click" on the digiti IV dextra when straightened after flexi

Diagnose

TRIGGER FINGER DIGITI IV MANUS DEXTRA

therapy
Infus RL Premed Broadced 1 G

Operative

PRO RELEASE DIGITI IV MANUS DEXTRA

THERAPY
INFUS RL diganti dengan amino

fluid Injeksi Ketorolac 3 x 30 mg Broadced 2 x 1 G (ganti oral)

Vital Sign
Blood presurre

120/80 mmHg Pulse : 84x/ minute Temperature : 36 C Respiratory : 20 x/ minute

DIGITI IV DEXTRA Look dextra Feel pulse (+) : there is scar at palmar

: pain (+), edema (-),

Movement not optimal

: flexi movement is

patient is allowed to go home

THERAPY
CIPROFLOXAXIN 2 X 500 MG ASAM MEFENAMAT 2 X 500 MG Q10DS 2 X 1

22 oktober 2012

 Patients come to the Orthopaedic

Clinic for control. From the results obtained diagnose that the patient had no complaints, Ring Of Motion (ROM) is good. The patient was able to move his hands, it can be activity as usual, and was able to use his hand to write.