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    Amputatic Injury

    Uploaded by

    IndraYudhi
    dr. Rizaldi

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Amputatic Injury

    Uploaded by

    IndraYudhi
    54 views16 pages
    dr. Rizaldi

    Original Title

    amputatic injury.pptx

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    © © All Rights Reserved

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    dr. Rizaldi

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    54 views16 pages

    Amputatic Injury

    Uploaded by

    IndraYudhi
    dr. Rizaldi

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    You are on page 1of 16

    Patient Identity

    • Name : Sofyan
    • Age : 47 years old
    • Sex : Male
    • Address : Lamkuk Seulimum Aceh Besar,
    Aceh Besar
    • MR : 0-84-28-61
    • Hp : 085235164873
    • Admission : 03.20 PM
    Time Response
    Date/hou Exami Laboratory Radiology Hour of Date/ho Supervisor
    r patient nation Examination Examination Diagno ur
    came to hour stics patient
    ER Send Result Send Result out from
    ER
    03 03.20 03.30 05.20 03.40 04.20 05.00 04 dr. Safrizal
    May PM PM PM PM PM PM May Rahman,
    2017 2017 SpOT

    03.20 PM OK
    Chief Complaint
    • Pain and inability to moving of the 5th finger of the
    right hand

    Present illness history


    • The patient was referred from Aceh Besar District
    Hospital to Zainoel Abidin Hospital Emergency Room
    with a chief complaint Pain and inability to moving of
    the 5th finger of the right hand happening 4 hours ago.
    • Initially the patient was hunting hog at forest and
    suddenly the hog counter attack him and his hand was
    bitten by hogs.
    • There was no trauma at the other part of body
    Physical examination
    Primary Survey
    • Airway : Clear
    • Breathing : Spontaneous, 20 breaths/min.
    • Circulation : Pulse : 88 beats/min
    • Disability : GCS E4V6M6 : 15, isochoric pupil
    (3 mm/3 mm), light reflex (+/+)
    • Exposure :
    L/S at the right hand
    • L : Wound (+), stump (+)
    • F : Pain (+), NVD (+)
    • M : ROM limited
    • Vas : 4
    Assessments:
    1. Traumatic amputated of the 5th fingers of the
    right hand
    Management
    • Stop oral intake
    • IVFD RL 2400 cc
    • Inj Cefazoline 1 gr
    • Inj Ketorolac 30 mg
    • Inj Tetagam 250 IU
    • Laboratory examination
    • Radiology examination
    Laboratory result
    • Hemoglobin : 14.1 gr/dl
    • White Blood Count : 14.200 mg/ ul
    • Platelets : 285.000/ul
    • Hematocrit : 42 %
    • CT/BT : 7’/2’
    • Blood glucose ad random : 109 mg/dl
    Radiology Results
    Manus AP-Oblique
    • There was discontinuity of the phalanx medial of the
    5th finger
    Diagnose
    1. Traumatic amputated of the 5th fingers of the right
    hand

    Consult to orthopedic division


    • Debridement + Repair stump emergency
    Operative Report
    • Performed debridement with NaCl 0,9 %, povidonie
    iodine and H2O2
    • Performed repair stump of the 5th finger of the right
    hand
    • Wound operation closed by primary suture
    Post operative diagnose
    • Traumatic amputated of the first finger of the left
    hand (ICD 10 CM M66.20)
    Follow up
    Date S O A P
    06 Pain General condition : Post repair stump due to : • Head Up 30o
    May (-) good • IVFD RL 2100 cc/24
    2017 BP : 110/80 mmHg 1. Traumatic amputated of hours
    HR : 88 beat/minute the first finger of the • Cefazoline Inj. 1
    POD 2 RR : 20 left hand (ICD 10 CM gr/12 hours
    breaths/minute M66.20) • Ketorolac inj 30
    T : 36.9 oC mg/8 hours
    • Ranitidine inj 50
    S/L at the right hand mg/ 12 hours
    L : gauze was dry
    F : pain (+) • wound care

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