IDENTITY

Name : Mr. I
Age : 21 years old
Sex : Male
Address : konawe selatan
Admission : October 30 2017
Doctor in charge : dr. Saktrio Darmono S, Sp.BP-RE
 Chief complain : pain at the right hand post electrical injury

History Taking : the patient admit to Hospital with pain at the right
hand because of the exposed electrical 1
week ago. Pain felt continously and pulsed.
History of electrical trauma 2 month ago
 Primary Survey

A: Clear
B: RR : 22 x/mnt, spontaneous, symmetric, and thoracoabdominal type.

C: BP : 110/70 mmHg, Pulse : 92 x/mnt, adequate, regular.

D: GCS 15 (E4M6V5)

E: T: 38.0C
Secondary survey
Regio
antebrachialis, carpalis and manus
I : wound, udem, necrosis
P : tenderness (+)
Planning
Routine blood cell
Chemistry blood cell
WORKING DIAGNOSIS : Necrosis at the right hand

MANAGEMENT :
IVFD
Antibiotic
Antipiretic
Analgetic
H2RA
Consul plastic surgery
 Thank You

BAGIAN ILMU
BEDAH
Dwi Rahmad Setiawan