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MORNING REPORT

SELASA, 22 MEI 2018


(21.00 – 04.00)

1 DM Paskal, DM Maya
Name : Mr. MR
Age : 39 tahun
Sex : Laki-laki
Address : Sikumana

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ANAMNESIS
Chief Complaint : Rigid on the whole body
Present Complaint: Patients complain of his whole
body was stiff from 1 day before entering the hospital.
Patients complain of difficulty opening mouth,
swallowing, and talking. Patients claim to be willing
when drinking water. 1 week ago, the patient's left
hand was affected by the paddy machine and the
patient had several open sores on the left hand, the
little finger had droped out, and fracture of the left
wrist. Patients
3 only use traditional medicine.
Secondary Survey
GCS: E4V5M6, time and people oriented good
BP 130/70 mmHg, HR x/minute, T:, RR
Kepala: normocephali
Mata: pupil isokor (3mm/3mm), RCL (+/+), Ikterik (-/-), anemia
(-/-)
Telinga: darah (-/-), otorrhea (-/-)
Hidung: darah (-/-), rhinorea (-/-)
Mulut: darah (-)
Leher: pembesaran KGB (-), teraba massa (-)

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PHYSICAL EXAMINATION
 Blood Pressure : 130/70 mmHg
 Heart rate : 106 times/minute
 Respiration rate : 22 times/minute
 Temperature : 37,1oC
 SpO2 : 97 %
 GCS : E4V5M6, good orientations

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 Head : Normochepaly, Lession (-)
 Eye : Conjungtiva anemis (-
/-), pupil isocor, pupil reflex (+/+)
 Ear : Othorrea (-/-)
 Nose : Epistaxis (-/-), rinorhea (-/-)
 Mouth : Trismus (+) 1 cm
 Neck : Lymphadenopathy (-)
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Thorax
Inspection : Chest expansion symetric
Palpatin : Vocal fremitus (R=D), mass (-), crepitation (-)
Perkution : Sonor (+/+)
Auscultation: Vesiculer (+/+)
Cor : s1s2 single, regular, murmur (-), gallop(-)

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Abdomen
Inspection : Flat
Auscultation: Peristaltic sound (+) normal
Palpation : Distended (+), Defans muscular (-)
Perkution : Tympani

Ekstremitas:
 Upper :
Look : Multiple vulnus laseratum on the left manus, amputated of the medial
phalanx left digiti V, swelling (+)
Feel : warm, a. radialis pulse (+), tendernes (+), CRT<2 second
Move : Limited ROM
 Lower :
Look : swelling (-)
Feel : warm, a. Dorsalis pedis (+), tendernes (-), CRT<2 second
Move : Normal ROM 8
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ASSESMENT:
POST AMPUTATUM DIGITI V SINISTRA
AND CLOSED FRACTURE ON
SUSPECT TETANUS

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TREATMENT:

- IVFD NACL 0.9% 20 GTT/MINUTE


- TOILET WOUND TREATMENT
- INSSTAL SPLANK
- TETANUS IMMUNE GLBULIN (TIG) 500 UNIT IM
- CEFTRIAXON INJECTION

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Thank You