ORTHOPEDIC

SHORTCASE

SITI AFRIANTY NUR. HASAN (K1A111057)

Pembimbing : dr. Mario Widjaya,M.Kes, Sp.OT

SMF ILMU BEDAH FAKULTAS KEDOKTERAN UHO

  Name : Mr. B
 Age : 31 years old
 Sex : male
IDENTITY  Address : Mandike Island
 Occupation : Fisherman
 Admission : November, 22th 2018
 Doctor in charge : dr. Mario Widjaya,M.Kes, Sp.OT
  Chief Complain : wound at the right hand
 Anamnesis :
Since 6 months ago. Initially in a boil the
size of a corn seed appears, then broke into a
wound. The cause was unknown.
HISTORY The other complaint : Pain (+)
 History of previous medication (-)
TAKING  There was history of same complain (+) Amputated foot thumb in
2017
 There was history of smoker
 There was no history of infection : Fever (-), Cough(-)
 There was no history decreased appetite (-), weight loss(-)
 History of illnes :
-DM (-) and Hipertention (-)
 Composmentis,
GENERALIZED Moderate illness,
STATE Good nutritional state
 TD : 120/80 mmHg
HR : 80 x/m, strong, reguler
VITAL SIGN RR: 20 x/m, thoracoabdminal typ,
symmetrical
T : 36,5/ axillary
VAS : 6/10
 Status Present
Head : Within Normal Limit
Face : Within Normal Limit
Eyes : Within Normal Limit
Nose : Within Normal Limit
Mouth : Within Normal Limit
Ears : Within Normal Limit
Neck : Within Normal Limit
Chest : Within Normal Limit
Abdomen : Within Normal Limit
Upper Limb : Localized
Lower Limb : Within Normal Limit
Genital : Within Normal Limit
 LOCALIZED STATE

Right Hand Region

Inspection : Deformity (+), Swelling (+), eritema (+), necrotic wound (+)
Palpation : tenderness (+)
ROM : Active and Passive motion was limited due to pain
NVD : Decreased sensibility, CRT Cannot be evaluated
CLINICAL PICTURES
 Laboratorium Finding

Chemistry Blood
Test 22/11/2018
Parameter Result Ref value

GDS 173 70 - 180

Ureum - 15-40

Creatinin - 0,5-1,0

SGOT - <31

SGPT - <31
 Necrotic digiti
V Manus
Dextra
DIAGNOSED

DD
Buerger Disease
Osteomielitis
NON FARMACOLOGY
FARMACOLOGY
Rest
IVFD
Elevasi
Analgetic
Nutrition
Antiobotic
Hygine
H2RA

CONSULT ORTHOPEDIC SURGERY

THANK YOU