MUHAMMAD NUR SIREGAR/

MALE/17 yo

WEDNESDAY, 18 TH JUNE
2014

 Chief complaint : inability to extent his toe

while working or sitting
It has been occured since 3 hours before
admitted to Emergency Unit Pirngadi General
Hospital. Previously, patient admitted that he
kicked an iron beam with his back right leg and
suffered lacerated wound and bleeding. Then the
patient went to clinic and the wound were
cleaned, sutured, and the patient was given
injection medicine. Patient was referred to RSUPM
to receive further treatment. Fever, nausea,
vomitting werent found. History of defecation (+)
Normal. History of urine (+) Normal.
Previous Disease : Unknown
Previous Medication: ATS injection,

PRESENT STATUS

AWARENESS
: Alert
BLOOD PRESSURE : 130/70 mmHg
HEART RATE
: 80 x/min
RESPIRATORY RATE : 20 x/min
TEMPERATURE : 36,5 C

PHYSICAL EXAMINATION
Primary survey :
Airway
: clear
Breathing : spontaneous , RR : 20x /
minute
Circulation : acral cold, BP : 130/ 70
mmhg, HR
: 80 x/ minute
Disability : GCS: E4 M6 V5 = 15

PHYSICAL EXAMINATION
Secondary Survey
Head :
Eye : Conjungtiva anemic (-/-), sklera icteric (-/-)
Ear / Nose / Mouth : normal

Neck : tracheal deviation (-), lymph node

enlargement (-)
Thorax :

Inspection : fusiform symmetry

Palpation : Fremitus tactile right = left
Percussion : sonor
Auscultation : vesicular

Abdominal
Inspection : Symmetry, distention (-)
Palpation : soepel
Percussion : Tympani
Auscultation : Peristaltic (+) normal

Genitalia : Male, in normal limit

Extremitas superior :
in normal limit
Localize Status :
Regio dorsum manus sinistra
Look : delayed primary suture,
Feel : pain (+), crepitation (-)
A.dorsalis pedis pultation (+)
Move : ROM (-), DOF (+)

Laboratorium

Leucocyte: 10900 uL
Eritrocyte : 4,4 x 10
Hb
: 12,8 gr/dl
Ht : 38,0 %
PLT
: 274.000 uL
Ureum : 24 mg/dl
Creatinin : 1,69mg/dl
Uric acid : 9,2 mg/dl
Natrium : 150 mmol/dl
Kalium : 3,8 mmol/dl
Chlorida : 108 mmol/dl

Glukosa ad= 116 g/dl

SGOT
= 23 u/i
SGPT
= 21 u/i
PT
INR
APT

= 13,2
= 1,05
= 26,3

C : 14,6
C : 34,0

 Diagnose : tendon rupture o/t extensor

Therapy at emergency unit:
-Fasting
-IVFD RL 20 gtt/ minute
-inj. Ceftriaxone 1gr/12 hours
-inj. Ketorolac 30mg/8 hours
-inj. Tetagam 1 amp

Planning
Debridemant
Repair tendon
Back slap