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