Rafiudin

Male /26 yo
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 IDENTITY
Name : Rafiudin

Age : 26 years old / Male

Admission : October 6th, 2022 at 23.00

(Consulted from Digestive Surgeon division)

Registration : 995408

Status : JKN

Phone Number :
ALLOANAMNESIS

Chief Complain : Pain at right wrist

• Suffered since 1,5 months before admitted to Wahidin Sudirohusodo
General Hospital. The patient was riding a motorcycle when he collided
with a car and his hand was hit by a car. After the incident, the patient
was unable to move his right wrist due to pain. Patient was brought to
Morowali Hospital and underwent laparotomy surgery.
• There was no history of loss of consciousness
• There was no history of projectile vomiting
• There was history of going to bone setter one time
• The patient is a private employee of a mining company with right-hand
dominance.
• The patient was consulted from digestive surgeon department
GENERAL STATUS

• Conscious
• Vital Signs:
Blood pressure : 110/80 mmHg
Pulse rate : 88 beats per min
Respiratory rate : 20 times per min
Temperature : 36,7 0C
NRS : 4/10
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 CLINICAL FINDING

Right Forearm Region

Look : Deformity (+), Swelling (-), Hematoma (-), Wound (-)

Feel : Tenderness (+)

Move : Active and passive movement of elbow joint within normal limit
Active and passive movement of wrist joint cannot be evaluated due to
pain
NVD : Sensibility hypoesthesia at median distribution. Radial and ulnar artery
pulsation is palpable, capillary refill time is less than 2 seconds.

Special : OK sign (-), Thumbs up (+), Finger Abduction (+), Finger Adduction (+)
Test
 DIAGNOSIS

• Neglected right distal radius fracture

• Chronic right carpal tunnel syndrome
• Right distal radioulnar joint injury
• Suspect billiary leakage post abdominal blunt trauma
• Liver rupture segment IV B grade III post laparotomy
• Bilier Evaluation
• Adhesiolysis day-30
 MANAGEMENT
• ORIF Distraction plate