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B. ANNAMESIS
Main complaints: Open wound on the right hand on the fourth finger and finger to V
interrupted accompanied by open wound on the left hand on the second finger.
Patients present with open wound in the right hand on the fourth finger and finger
to V interrupted accompanied by open wound in left hand on second finger. Patients
say open sores on the hands are caused by work accidents. This has been
experienced since this morning. The wound was painful and began to be difficult to
move.
medical history :
- The patient denies ever suffering from Diabetes Mellitus and previous
Hypertension
impression: moderate
Nutrition: good
Vital signs:
- Temperature: 36.6 oC
Localized Status:
Look: Open fracture phalanx distal digiti IV manus dextra with open fracture phalanx
medial digiti II manus sinistra.
Feel: Digiti IV pain, V manus dextra (+), tenderness digiti II manus sinistra (+), capp
refill (<2 '),
Move: Limitations of movement of flexion and extension on digiti IV, V manus dextra
and digiti II manus sinistra.
Investigation
18 april 2017
- Hb : 12,0 ( N : 14-18 gr/dl)
- Leukosit : 13.600 ( N : 4500 10.700/ul)
- Eritrosit : 4,57 ( N: 4,5-6,0 juta/ul)
- Trombosit : 205.000 ( N: 150.000-400.000/ul)
- Hematokrit : 50,5 ( N: 42-54%)
- GDS : 105 ( N: <200mg/dl)
DIAGNOSE
Open fracture phalanx distal digiti IV manus dextra with open fracture phalanx
medial digiti II manus sinistra.
MANAGEMENT
Operative:
Medikamentosa:
- IVFD RL 20 tpm
- Ketorolac amp / 8j / iv
date of admittance
history of illness
Patients came with open wound in the right hand on the fourth finger and the five
finger interrupted accompanied by open wound in left hand on second finger.
Patients say open wound on the hands are caused by work accidents. This has been
experienced since this morning. The wound was painful and began to be difficult to
move.
wound
accompanied
interrupted
well nourished
moderate illnes
tenderness
Tanggal masuk
Sejarah penyakit
Pasien datang dengan luka terbuka di tangan kanan pada jari keempat dan kelima
jari terganggu disertai luka terbuka di tangan kiri dengan jari kedua. Pasien
mengatakan luka terbuka di tangan disebabkan oleh kecelakaan kerja. Ini sudah
dialami sejak pagi ini. Luka itu terasa sakit dan mulai sulit bergerak.
luka
Disertai
Terganggu
Baik gizi
Sakit sedang
Kelembutan
HEALING
car accidents
Direct blow
Repetitive forces
Pathology
Signs and Symptoms
Swelling or tenderness
pain
Numbness
Bleeding
Physical Examination:
Alignment.
Neurovascular status
Radiographic studies:
PENYEMBUHAN
kecelakaan mobil
Pukulan langsung
Kekuatan berulang
Patologi
rasa sakit
Mati rasa
Berdarah
Pemeriksaan fisik:
Penjajaran.
Status neurotoksik
Studi radiografi: