SHORT CASE

BENAZIR AMRINNISA Y
 IDENTITY

Name : Mr. I
Age : 25 years old
Address : Morosi
Admission : February, 25th 2020 (17.10 WITA)
Doctor in Charge : dr. Moh Rizal Alisi, Sp.OT
 PRIMARY SURVEY (17.10 P.M)
A
Clear, Cervical Spine Control

RR = 24x/min, symmetric, spontaneous, B

thoracoabdominal type.

C
BP = 140/90mmHg, HR = 104 x/min, regular, strong,
CRT < 2 minutes

D
GCS 15 (E4M6V5), pupil : Isokor : 2 mm/ 2mm,

E
T = 37,60C (axillary)
 HISTORY TAKING (ALLOANAMNESIS) (17.15 P.M)
• Chief Complain :
Pain In The Fingers Of The Left Hand

• Anamnesis :
• Pain Felt Since 3 Hours Ago Due to Falling Wood

• Mechanism Of Trauma : the patient wants to move the wood that is next to him
accidentally the wood falls and hits the patient's hand. other mechanisms are
not known
• History Of Trauma :
There was no history of unconsciousness
There was no history of bleeding from mouth,nose, and ear
There was no history of alcoholic
There was no history of previous treatment
 GENERAL STATE (17.30 PM)

General State : Composmentis, moderate illnes,

good nourish

Head : Within Normal Limit Chest : Within Normal Limit

Face : Within Normal Limit Thorax : Within Normal Limit
Eyes : Within Normal Limit Abdomen : Within Normal Limit
Nose : Within Normal Limit Hand : Localized State
Mouth : Within Normal Limit Upper limb : Within Normal Limit
Ears : Within Normal Limit Lower limb : Within Normal Limit
Neck : Within Normal Limit
 LOCALIZE STATE
Manus Sinistra Region

• Inspection
Deformity (+), Swelling (+) Eritema (+), Vulnus Laceratum size 2 x 1 cm.

• Palpation
Tenderness (+), crepitation (difficult to judge)

• ROM
Active and Pasive on phalangs digiti IV manus sinistra limited due to pain

• NVD
Sensibility (+), CRT < 2 second
CLINICAL FINDING
X-RAY MANUS SINISTRA
Plan of Diagnostic

X-RAY PALM
 DIAGNOSIS

OPEN FRACTURE DIGITI IV MANUS SINISTRA

 MANAGEMENT

NON-PHARMACOLOGY PHARMACOLOGY
• REST • IVFD
• IMMOBILISATION • ANALGETIC INJECTION
• WOUND CARE • ANTIBIOTIC INJECTION
• EDUCATION CONSULT ORTHOPEDIC
SURGEON
 THANK YOU

ORTHOPEDIC SURGERY
DEPARTMENT