Morning Report

IDENTITY

Name : Mr. TNH

Age : 21 years old
Adress : Konsel
Admission : May, 1th 2018
DPJP : dr. Rizal Alisi, Sp.OT
 Chief complain :
Pain at the left hand
 Anamnesis :
suffered since 1 hour ago after a work accident
 Mecanism of trauma :
the patient was working triplex, and then the patient’s finger hit by
gerinda machine
 History of trauma :
History of unconsciousness (-), nausea (-), vomoting (-)
History of bledding from nose (-), ears (-), and mounth (-)
History of alcohol consumption (-), drugs consumption (-)
History of previous medication (-)

HISTORY TAKING
PRIMARY SURVEY
A Clear

RR 20x/min regular, spontaneous

thoracoabdominal type, symmetrical B
BP 120/80 mmHg
C HR = 80 x/min regular, strong

GCS 15 (E4V5M6), isochoric pupil,

Ø : 2.5 mm/2.5 mm, light reflex +/+ D
E T = 36,60 C (axillary)
 SECONDARY SURVEY
Head : Within normal limits lower limb : Local state
Eyes : Within normal limits
Nose : Within normal limits
Mouth : Within normal limits
Ears : Within normal limits
Neck : Within normal limits .
Chest : within normal limits
Abdomen : Within normal limits
Upper limb : Within normal limits
Local status regio manus sinistra

Look : Deformity (+), hematom (-), edema (-), scissum wound

(+) size 7x3
Feel : Tenderness (+), krepitation (+)
ROM : Active and pasive movement interphalangs joint limited
due to pain
NVD : Sensibility is good, artery radialis and ulnaris is
palpable, CRT < 2 second.
 Plan of Diagnostic
 X-ray manus sinistra region, ap/lat view
 Counting blood cell
 Routine blood test

WBC 9,57 U/L

HGB 12,2 mg/dL
PLT 161 U/L

Laboratory Findings
DIAGNOSIS
Open fracture at the os phalang
distal digiti III - IV manus
sinistra
 MANAGEMENT
FARMAKOLOGI
NON FARMAKOLOGI • IVFD
 Wound care • Analgesic
 Bed rest • Antibiotic
• H2RA
• Consult Orthophedi
Thank You