BAGIAN ORTHOPEDI

MUCHAMMAD AMAL MAJID

111 2016 2156

OPEN FRACTURE PHALANX

PROXIMAL DIGIT I PEDIS DEXTRA
 CASE
Identitas Pasien
REPORT
PATIENT’S IDENTITY

Nama : Tn. M
HISTORY TAKING

PHYSICAL Umur : 29 tahun / Laki-laki

EXAMINATION

CLINICAL FINDING
Tanggal Masuk : 11 Maret 2019

Registration : 262071
INVESTIGATION

ASSESMENT

THERAPY
 CASE
REPORT
HISTORY TAKING

PATIENT’S IDENTITY KU: Nyeri pada jempol kaki kanan

 Anamnesis Terpimpin : Pasien datang dengan keluhan
HISTORY TAKING
nyeri pada jempol kaki kanan yang dialami sejak 3 jam
PHYSICAL yang lalu sebelum masuk rumah sakit. Nyeri kepala (-),
EXAMINATION Mual (-), Muntah (-).
CLINICAL FINDING  Mekanisme trauma: Pasien sedang mengendarai motor
tiba-tiba muncul motor dari arah yang berlawanan
INVESTIGATION kemudian menabrak pasien sehingga pasien terjatuh.
 Riwayat pengobatan: tidak ada
ASSESMENT

THERAPY
 CASE
PRIMARY SURVEY
REPORT
PATIENT’S IDENTITY
Airway • Bebas

HISTORY TAKING
• 20x/min, thoracoabdominal, spontan,
PHYSICAL
Breathing symetric.
EXAMINATION

• Td 110/80mmHg, HR 72x/min, reguler,

CLINICAL FINDING Circulation kuat angkat

INVESTIGATION • GCS 15(E4M6V5), light reflex +/+ ,

Disabilty pupil isokor, Ø : 2.5mm/2.5mm,
ASSESMENT

THERAPY Exposure • Temp 37.5°C (axilla)

 CASE
SECONDARY SURVEY
REPORT
PATIENT’S IDENTITY  Regio Phalanx Pedis Dextra
 Look :
HISTORY TAKING
Deformitas (-), edema (-), luka (+), Bone expose (+)
PHYSICAL  Feel :
EXAMINATION
Nyeri tekan (+)
CLINICAL FINDING
 Movement :
Gerakan aktif dan pasif sulit dinilai karena nyeri
INVESTIGATION
 NVD :
ASSESMENT
Sensibilitas normal, pulsasi A. Dorsalis Pedis (+), CRT >
THERAPY 2 detik
 CASE
CLINICAL FINDING
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

ASSESMENT

THERAPY
Phalanx Digiti 1 Pedis Dextra
 CASE
RADIOLOGY FINDING
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION X- Ray Dorsum
Pedis Dextra
CLINICAL FINDING
AP/Oblique

INVESTIGATION

ASSESMENT

THERAPY
Fraktur Comunitif phalanx proximal
Pedis Dextra
 CASE
REPORT
PATIENT’S IDENTITY
LaboratoriumHASIL
TEST SATUAN NILAI RUJUKAN

HISTORY TAKING
WBC 9.450 /µl 4.000-10.000

PHYSICAL HB 13,3 gr/dL 11-16

EXAMINATION
PLT 265.000 /µl 100.000-300.000

CLINICAL FINDING HCT 40,7 % 37-54

CT 6’30” Menit 1-7

INVESTIGATION BT 3’15” Menit 5-15

HBsAG Non-reaktif Non-Reaktif

ASSESMENT

THERAPY
 CASE
INTRA OPERATION
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION

CLINICAL FINDING

INVESTIGATION

ASSESMENT

THERAPY
 CASE
DIAGNOSIS
REPORT
PATIENT’S IDENTITY

HISTORY TAKING

PHYSICAL
EXAMINATION  Open Fracture phalanx proximal
CLINICAL FINDING digiti I Pedis Dextra
INVESTIGATION

ASSESMENT

THERAPY
 CASE
THERAPY
REPORT
PATIENT’S IDENTITY
 IVFD RL 20 tpm
HISTORY TAKING  Cefotaxime 1 gr/12j /iv
PHYSICAL  Ketorolac 30 mg/8j/iv
EXAMINATION
 Ranitidin 50 mg/ 12j/iv
CLINICAL FINDING
 Immobilisasi
INVESTIGATION  Rencana operasi pemasangan K-Wire
ASSESMENT

THERAPY
THANK YOU