MORNING

REPORT
September 22th, 2023
IDENTITY

● Name : Mr. Wahid

● Age : 42 years old
● Gender : Male
● Address : Batu
● Arrival Date : September 22th, 2023
● Patient Type : Trauma
 PRIMARY SURVEY
Incident date: September 22, 2023 at 08.30 WIB
Arrival Date: September 22, 2023 at 09.00 WIB

Main Complaint : pain in the ring and little finger of the right
hand

Anamnesis: pain in the ring finger and little finger of the right
hand with VAS 8-9 after being hit by a 50kg LPG while working.

MOI: The patient fingers was hit by a 50kg LPG while working.
 Examination Initial Diagnosis Action
Airway: Patent -
Patent, gurgling (-), stridor (-), snoring (-)
Breathing: Spontaneous -
Look: symmetrical chest wall movement, lesion (-)
Feel: the patient breathes spontaneously, no additional breath
sounds, rib crepitations (-), step defect (-)
RR: 17x/minute
SpO2 : 99% on RA
Circulation: Stable hemodynamic -
BP: 124/82 mmHg
HR: 87x/m
 Examination Initial Diagnosis Action
Disability • Susp. Rupture Pressure &
GCS: 456. PBI: 3 mm/3mm. Direct light reflex +/+, Indirect tendon digiti V wound care
light reflex +/+ manus D
Regio Manus D • Vulnus appertum
• L: digiti IV manus D
• -vulnus appertum size 0.5x1cm in digit IV distal phalange,
hematome (+), bone exposed (-), active bleeding (-),
edema (+), erythema (+), deformity (-)
• -vulnus appertum size 2x1cm on the V digit of the distal
phalange, dirty, tendon exposed (+), active bleeding (+),
edema (+), erythema (+), deformity (+)
• F:- tenderness (+) os digiti V manus D, felt warm, crepitus
(-), step off (-), radial artery pulse (+), felt strong, Sensory
stimulation attempt (+)- tenderness (+) os digiti IV manus
D, felt warm, crepitus (-), step off (-), radial artery pulse (+),
felt strong, Sensory stimulation (+)
• M: ROM Limitation (+)
Exposure
T : 36.7° C. CRT <2s, red warm dry acral, active bleeding (-)
 SECONDARY SURVEY

Symptoms: The patient complained of pain in the ring and little finger of the right
hand with a VAS of 7-8 after being hit by a 50kg LPG cylinder while working.
Fingers feel slightly numb, syncope (-), headache (-), nausea (-), vomiting (-),
retrograde amnesia (-).The patient has not been given any intervention.
Allergy: -
Med: -
Past illness: Asthma -, HT -, DM -
Last meal: 08.00 (September 22th ,2023)
Event: The patient fingers was hit by a 50kg LPG while working
 GENERALIST STATUS

GCS : 456
TD : 113/86 mmHg
HR : 77/menit
RR : 17x/menit
T : 36.2 C
SpO2: 98% on RA
 PHYSICAL
EXAMINATION
THORAX :
Cor:
HEAD/NECK: Inspection: ictus cordis invisible, lesion (-),
Palpation: ictus cordis palpable at ICS 5 MCL S,
Head Percussion: Right heart border at PSL D ICS 4,
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), heart border Left at MCL S ICS 5
Isochor pupil diameter 3mm/3mm, Light reflex direct Auscultation: S1 S2 single, regular, murmur (-),
and indirect +/+ gallop (-)
Ears : bloody Otorea (-/-)
Nose : epistaksis (-/-) Pulmo:
Mouth: cyanosis (-), trismus (-) Inspection: normal chest wall shape, retraction
(-), looks symmetrical (+/+)
Neck : Palpation: symmetrical D/S chest wall
Inspection: scar (-), mass (-), tracheal deviation (-) movement
Palpation: tenderness (-), enlarged lymph nodes (-) Percussion: sonor all lung fields
Auscultation : Bruits (-) Auscultation: Ves/Ves, rh (-/-), wh (-/-)
 • F:
PHYSICAL - tenderness (+) os digiti V manus D, felt warm,
EXAMINATION crepitus (-), step off (-), radial artery pulse (+),
Abdomen: felt strong, Sensory stimulation (+)
Inspection : Flat, injury (-), lesion (-) - tenderness (+) os digiti IV manus D, felt warm,
Auscultation : Bowel sound (+) 17x/minute crepitus (-), step off (-), radial artery pulse (+),
Palpation : Flat, soft, superficial tenderness felt strong, Sensory stimulation (+)
(-), deep tenderness (-) • M: ROM Limitation (+)
Percussion : Timpany all abdomen fields Flexion of DIP joint digit I 0-90°
Extension of DIP joint digital I 0-5°
Extremities : Dry warm acral, CRT <2 s Flexion of DIP joint digital II 0-90°
Extension of DIP joint digital II 0-5°
Localist status Flexion of DIP joint digit III 0-90°
Manus Dextra Region Extension of DIP joint digital III 0-5°
• L: Flexion of DIP joint digit IV 0-90°
-vulnus appertum size 0.5x1cm in digit IV distal Extension of DIP joint digital IV 0-5°
phalange, hematome (+), bone exposed (-), active Flexion of DIP joint digit 0-50°
bleeding (-), edema (+), erythema (+), deformity (-) Extension of DIP joint digital V 0-3°
-vulnus appertum size 2x1cm on the V digit of the Digiti 1-3 100%
distal phalange, dirty, tendon exposed (+), active Digiti 4 94%
bleeding (+), edema (+), erythema (+), deformity (+) Digiti 5 95%
CLINICAL
PICTURES
 PROBLEM LIST & PLANNING
Problem List Initial Planning
Diagnosis Diagnosis
• Pain in the ring and little finger of the right hand with a VAS of 7-8 1.Susp. Xray manus D
after being hit by a 50kg LPG while working. Rupture AP/ oblique
• Fingers feel slightly numb tendon digiti CBC, FH
• Has not been given any intervention V manus D
Manus Dextra Region 2.Vulnus
L: appertum
-vulnus appertum size 0.5x1cm in digit IV distal phalange, hematome digiti IV
(+), edema (+), erythema (+) manus D
-vulnus appertum size 2x1cm on the V digit of the distal phalange, dirty,
tendon exposed (+), active bleeding (+), edema (+), erythema (+),
deformity (+)
F:
- tenderness (+) os digiti V manus D, felt warm
- tenderness (+) os digiti IV manus D, felt warm
M
Flexion of DIP joint digit 0-50°
Extension of DIP joint digital V 0-3°
Digiti 4 94%; Digiti 5 95%
Xray manus D AP/ oblique (22/09/2023 at RSKH)
 Laboratory Examination
CBC (23/09/2023)
Hb 15.5
WBC 8.580

Kimia Darah (21/09/2023)

Ureum 31.74 mg/dL
Creatinin P 1.13 mg/Dl
SGPT 19.5 U/L
SGOT 18.5 U/L

Koagulasi (23/09/2023)
PPT L 9.6 detik
APTT L 23.0 detik
 PROBLEM LIST & PLANNING
Problem List Definitive Planning
Diagnosis
• Pain in the ring and little finger of the right hand with a VAS of 7-8 after 1.Avulsi digiti • Pressure
being hit by a 50kg LPG while working. IV, V manus • Wound care
• Fingers feel slightly numb D • Pro
• Has not been given any intervention debridement,
Manus Dextra Region exploration
L: • IVFD RL 20
-vulnus appertum size 0.5x1cm in digit IV distal phalange, hematome (+), tpm
edema (+), erythema (+) • Inj Ketorolac
-vulnus appertum size 2x1cm on the V digit of the distal phalange, dirty, 30 mg
tendon exposed (+), active bleeding (+), edema (+), erythema (+), deformity • Inj Ranitidine
(+) 50 mg
F: • Inj Ceftriaxone
- tenderness (+) os digiti V manus D, felt warm 2x1gr
- tenderness (+) os digiti IV manus D, felt warm
M
Flexion of DIP joint digit 0-50°
Extension of DIP joint digital V 0-3°
Digiti 4 94%; Digiti 5 95%
XRAY manus D AP/oblique: soft tissue oedema manus D, no discontinuity
THANK YOU