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    Duty Report: Annisa Ayu Rahmawati Nazza Rizky Ramdhagama Martha Simona Nurjannah

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    sasoy
    - A 60-year-old male patient presented to the emergency department after being hit by a motorcycle while crossing the street, complaining of pain in his right hand. - Examination revealed swelling and abrasions on the right hand with limited range of motion due to pain. - Working diagnosis was closed fracture of the proximal phalanges of fingers 4 and 5 on the right hand. The patient was treated with antibiotics, analgesics, bed rest, and wound care while consulting orthopedics for further management.

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    Duty Report: Annisa Ayu Rahmawati Nazza Rizky Ramdhagama Martha Simona Nurjannah

    Uploaded by

    sasoy
    13 views13 pages
    - A 60-year-old male patient presented to the emergency department after being hit by a motorcycle while crossing the street, complaining of pain in his right hand. - Examination revealed swelling and abrasions on the right hand with limited range of motion due to pain. - Working diagnosis was closed fracture of the proximal phalanges of fingers 4 and 5 on the right hand. The patient was treated with antibiotics, analgesics, bed rest, and wound care while consulting orthopedics for further management.

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    Lapjag 26 sep.pptx

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    - A 60-year-old male patient presented to the emergency department after being hit by a motorcycle while crossing the street, complaining of pain in his right hand. - Examination revealed swelling and abrasions on the right hand with limited range of motion due to pain. - Working diagnosis was closed fracture of the proximal phalanges of fingers 4 and 5 on the right hand. The patient was treated with antibiotics, analgesics, bed rest, and wound care while consulting orthopedics for further management.

    Copyright:

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    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    13 views13 pages

    Duty Report: Annisa Ayu Rahmawati Nazza Rizky Ramdhagama Martha Simona Nurjannah

    Uploaded by

    sasoy
    - A 60-year-old male patient presented to the emergency department after being hit by a motorcycle while crossing the street, complaining of pain in his right hand. - Examination revealed swelling and abrasions on the right hand with limited range of motion due to pain. - Working diagnosis was closed fracture of the proximal phalanges of fingers 4 and 5 on the right hand. The patient was treated with antibiotics, analgesics, bed rest, and wound care while consulting orthopedics for further management.

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    Duty Report

    Annisa Ayu Rahmawati


    Nazza Rizky Ramdhagama
    Martha Simona
    Nurjannah
    Dokter Jaga Pasien
    Trauma = 1 pasien
    Non-Trauma = 0 pasien
    Rawat inap = 1 pasien

    Nama Usia Diagnosis


    Mr. J 60 years old Closed Fracture Proximal Phalanges
    Digiti 4,5 Manus Dextra
    1st case
    Identity & History

    Name M Past Medical History:


    Sex Male Diabetes Melitus (+)
    Age 60 y/o

    Family History:
    (-)
    Chief complaint:
    Other complaints:
    Pain on his right hand
    Swelling on the right hand
    20:15 pm
    16:45 pm IGD
    (before RSUD
    admitted) IGD Koja

    Patient complaints
    Patient was crossing pain at his right
    over the street when the hand
    motorcycle hit him on
    the right hand
    History of Present Illness

    Patient claimed that he got injured when he crossing over the


    street. He was hit by the motorcycle.
    Loss of conciousness post trauma (-), nausea and vomitus (-)
    Past medical history: hypertension (-), dm (+), asthma (-),
    congenital/acquired heart disease (-), past allergy history (-).
    Primary Survey

    Airway :
    Airway obstruction (clear)
    Breathing :
    Spontaneous breathing (+), retraction (-), RR: 20 x/mins
    Circulation :
    Pulse (+, regular), cold extremities, BP: 120/90, HR: 112 x/mins, Temp: 36.0 C, CRT <2 sec
    Disability :
    GCS (E4M6V5) = 15
    Secondary Survey

    ●Head : Bleeding (-), swelling (-), tenderness (-), hematoma (-)


    ●Eyes : Eyebrow (-), Isokor 3mm/3mm, CA (-/-), SI (-/-)
    ●Nose : hair nose (-), Bleeding (-)
    ●Ear : Normotia, bleeding (-)
    ●Mouth : Mucosa redness, cyanosis (-),
    ●Neck : Enlargement of LN (-)
    Thorax :
    • Inspection : Symmetrical
    • Palpation : Vocal fremitus & tactile symmetrical
    • Percussion : resonance in both lungs
    • Auscultation : Vesicular, Rh -/-, Wh -/-; Heart sound I-II normal

    Abdomen :
    • Inspection : Flat, mass (-),
    • Auscultation : Peristaltic sound (+), normoperistaltic
    • Palpation : Soft & non tender, distention (-)
    • Percussion : Tymphany
    Local state of right hand
    • Look: swelling, vulnus abrasion at
    dorsalis manus dextra regio with
    irregular shape, regular edge, base
    of wound soft tissue layer
    • Feel: pain on palpitation (+),
    pulsation (+)
    • Move: wrist extention, wrist
    flexion, abduction and opotition
    limited due to pain.
    Diagnosis and problem

    Working diagnosis:
    Closed Fracture Proximal Problems:
    Phalanges Digiti 4,5 Manus • Pain
    Dextra • Inflammation
    • Infection
    Management

    SURGERY NON SURGERY

    Consult orthopedy Pharmacology


    Ceftriaxone 2x1g
    Ketorolac 3x30mg

    Non-pharmacology
    Bed rest
    Wound care

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