Scribd Logo
Upload

Welcome to Scribd!

  • 15 views

    Duty Report 12 SEPTEMBER 2019: Annisa Ayu R Nazza Rizky R Valentina Salim Chandra Rhavi

    Uploaded by

    sasoy
    The patient presented with pain and active bleeding in his left index finger sustained from an injury while helping turn on a boat engine 2 hours prior. On examination, he had an open fracture of the left index finger with a 1.5cm irregular wound and limited range of motion. He was treated with wound cleaning, tetanus immunoglobulin injection, antibiotics, analgesics, wound closure, and finger immobilization.

    Copyright:

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

    Duty Report 12 SEPTEMBER 2019: Annisa Ayu R Nazza Rizky R Valentina Salim Chandra Rhavi

    Uploaded by

    sasoy
    15 views12 pages
    The patient presented with pain and active bleeding in his left index finger sustained from an injury while helping turn on a boat engine 2 hours prior. On examination, he had an open fracture of the left index finger with a 1.5cm irregular wound and limited range of motion. He was treated with wound cleaning, tetanus immunoglobulin injection, antibiotics, analgesics, wound closure, and finger immobilization.

    Original Title

    lapjag 12 sept.pptx

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The patient presented with pain and active bleeding in his left index finger sustained from an injury while helping turn on a boat engine 2 hours prior. On examination, he had an open fracture of the left index finger with a 1.5cm irregular wound and limited range of motion. He was treated with wound cleaning, tetanus immunoglobulin injection, antibiotics, analgesics, wound closure, and finger immobilization.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    15 views12 pages

    Duty Report 12 SEPTEMBER 2019: Annisa Ayu R Nazza Rizky R Valentina Salim Chandra Rhavi

    Uploaded by

    sasoy
    The patient presented with pain and active bleeding in his left index finger sustained from an injury while helping turn on a boat engine 2 hours prior. On examination, he had an open fracture of the left index finger with a 1.5cm irregular wound and limited range of motion. He was treated with wound cleaning, tetanus immunoglobulin injection, antibiotics, analgesics, wound closure, and finger immobilization.

    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 12

    DUTY REPORT

    12 SEPTEMBER 2019
    Annisa Ayu R
    Nazza Rizky R
    Valentina Salim
    Chandra Rhavi
    Tn. R (27 years)
    Chief complain: Patient presented with chief complain pain on his left
    index finger 2 hour before entering hospital

    Additional complains: Patient said there’s active bleeding on his left


    index finger, the bleeding has been controlled by firm pressure with
    sterile cotton pad, he had difficulty moving his left index finger, no
    fever, no nausea and vomitus, no diploplia, no blurry vision, there’s no
    scar on other site.
    History of present illness
     Patient presented with chief complain: Patient presented with chief complain pain on his left
    index finger 2 hour before entering hospital. Patient claimed that he got injured when he helped
    his brother to turn on the boat machine. Patient have difficulty moving his left index finger, no
    fever, no nausea and vomitus, no diploplia, no blurry vision, there’s no scar on other site. The
    bleeding has been controlled by firm pressure with sterile cotton pad and then go to Koja General
    Hospital due to lack of instruments.
    MECHANISM OF TRAUMA

     Patient claimed that he got injured when he tried to turn on the


    boat machine, his left index finger got stuck and almost got
    separated.
     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 causes paradoxical chest


    and abdominal movements (-).
    Breathing: symmetrical chest rise with spontaneous
    breathing, no use of the accessory muscles of
    respiration.
    Circulation: regular heart rate with good pulse volume,
    warm extremity, BP: 115/71mmHg, HR: 79x/menit,
    SpO2 99%
    Disability: GCS: E4M6V5 (15), CM
    SECONDARY SURVEY
    HEAD : NORMOCEPHAL, NO SCAR

    EYES : PUPIL REACTIVE 3MM/3MM isokor, CA


    (-/-), SI(-/-)

    NOSE : Laceration wound (+)

    EARS : NAD

    MOUTH : PINK, CYANOSIS(-)

    NECK : LYMPH NODES NO MASS (-)

    THROAT : T1/T1, NO DETRITUS, PINK


    Thorax Abdomen
    Inspection : symmetric chest expantion, effortless
    respiration, retraction (-), no scar.
     Inspection: flat, masses (-)
    Palpation: tenderness (-), normal vocal fremitus, masses  Auscultation: bowel sound
    (-) present, 6X/MIN
    Percusion: sonor throughout the pulmonary area  Palpation: tenderness (-),
    Auscultation: VS, ICS 5-6 sinistra . Rh (-/-), wh (-/-). defans muskular (-)
    HEART SOUND I & II REGULAR, NO MURMUR,
    NO GALLOP.  Percution: tympanic
    throughout the abdominal area
     Extremities: CRT <2, edema
    (-),
    Status Localist
    Look : open fracture at digiti 2 manus sinistra, size of the wound:
    diameter 1,5cm , irregular edge, well demarcated, with a connective
    tissue base, active bleeding (-).

    Feel : tenderness to light palpation (+), crepitation (+)

    Move: Limited range of movements


    Diagnosis
     Open fracture digiti 2 interphalanx sinistra
    Pharmacology

     Wound toilet with NaCl 0,9%, povidone iodine, H2O2,

     TIG (250IU,IM)

     Ceftriaxone 1g inj

     Ketorolac inj 30mg.

    Non pharmacology

     Wound closure

     Immobilisation Cruris

    You might also like

    pFad - Phonifier reborn

    Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

    Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


    Alternative Proxies:

    Alternative Proxy

    pFad Proxy

    pFad v3 Proxy

    pFad v4 Proxy