IDENTITY

Name : Mr. BH
Age : 28 years old
Sex : Male
Address: Torada
DPJP : dr. Saktrio D., Sp.BP-RE
Admission : September, 2nd
2017
 HISTORY TAKING

Chief Complain : Pain at the left thumb and index finger

Anamnesis :
The patient come to the hospital with complaint pain at the left thumb and index finger since
1 hour ago after have an accident.
Mechanism of trauma :
The patient was to hold a glass door that will falled, that cause the broken glass slicing the
thumb and index finger of the left hand.
There was no history of medicine.
 Primary survey
A Clear

RR 22 x/min, spontaneous
thoracoabdominal type, symmetrical B
C BP 140/70 mmHg
Pulse =80x/min, regular, weak

GCS 15 (E4M6V5), pupil isochors D

E T = 36.5 C (axillary)
Head: Normally
Secondary survey
Face : Normally
Eyes : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
Chest : Normally
Abdomen : Normally
Extremity
 Localized state
Left Manus Region
Inspection : Wound (+) vulnus laceratum at the thumb and index
finger with size 6.5 cm x 0.5 cm and 4.1 cm x 1.1 cm,
deformity (-), swelling (-), Hematome (-)
Palpation : Pain (+)
ROM : Active and passive motion of wrist and
metacarpophalangeal joint were normal
NVD : Good Sensibility, pulse of artery is palpable, CRT < 2
detik
Clinical Findings
 Planning Of Diagnosis

1. Routine Blood

2. X-Ray AP / Lateral view left Manus

 DIAGNOSIS

Vulnus Apertum Left Hand

 Management

IVFD

Antibiotic

Analgetic

H2R-antagonist

Plastic Surgeon Consult

 Thank You

BAGIAN ILMU
BEDAH