Morning Report

Tuesday, June 22 th, 2015

Team on duty
dr. Andria Saputra
( Jaga
dr. Aa Ahmad Dimyati
( Jaga
dr. Aswad Affandi
( Jaga
dr. Andri Feisal N
( Jaga 4 )
dr. Bobby Fermi S
( Jaga
dr. Avicenna Gatot
( Jaga
dr. Herdi Gunanta S
( Jaga
I.

1)
2)
3)
4)
5)
5)

Patient Identity
Name
: Wanti Asiah
Age
: 55 ayears old
Address
: Ds. Rabo, Kec. Darussalam, Aceh Besar
MR
: 987881
Hp
: 085362339768
Admission time: 12.01 WIB

Time Response
II.

Chief Complaint
Pain and difficulty moving 2nd finger of the left hand
Present illness history
The patient came to RSUDZA with a chief complaint Pain and
difficulty moving 2nd finger of the left hand since 1 hour ago. The patient
was cuting the grass at the garden, suddenly her hand was cut by
chopping knife. There was no trauma at the other part of body

III.

Physical examination
Primary Survey
Airway
: Clear
Breathing
: Spontaneous, 20 breaths/min.
Circulation : BP: 145/80 mmhg, Pulse : 100 beats/min
Disability
: GCS E4 V5 M6 : 15
Exposure
:
L/S at the left hand
L : Wound (+) size 4 cm, base of wound : bone, tendon exposed
(+)
F : Pain (+), NVD (-)
M : ROM limited (moving 2nd finger )

Secondary Survey
Head and neck
: in normal limit
Thorax
: in normal limit
Abdominal
: in normal limit
Upper Extremity
:
L/S at the left hand
L : Wound (+) size : 4 cm, base of wound bone, tendon exposed
(+)
F : Pain (+), NVD (-)
M : ROM limited (moving 2nd finger)
Lower Extremity

IV.

: in normal limit

Assessment
Ruptured of the tendon of extensor indices and tendon of extensor 2nd
digitorum of the left hand

V.

VI.

Management
Stop oral intake
IVFD RL 20 drips/min
Inj Cefazoline 1 g
Inj Ketorolac 30 mg
Inj Tetagam 250 IU
Laboratory examination
Laboratory result
Hemoglobin
: 12,6 gr/dl
White Blood Count
: 6.900 mg/ ul
Platelets
: 205.000/ul
Hematocrit
: 38 %
CT/BT
: 8/2
Glucose ad random
: 144 mg/dl

VII.

Diagnose
Ruptured of the tendon of extensor indices and tendon of extensor 2nd
digitorum of the left hand (ICD X M66.242)

VIII.

Consult to orthopedic division

Debridement and Repair tendon emergency

IX.

Operation Report
Performed debridement
Exploration at the wound with lazy S incision, there was total ruptured
of the tendon of extensor indices
Performed repair tendon of extensor indices with non absorbable 3-0
(Kessler modified procedure)
Wound operation closed by primary suture

X.

Post operative diagnose

Ruptured of the tendon of extensor indices and tendon of extensor 2nd
digitorum of the left hand (ICD X M66.242)

XI.

Follow Up

Date
22-62015
POD 1

S
pain
(-)

O
Vital sign
Blood pressure :
120/80 mmhg
HR : 100 beats/
minute
RR:20
breaths/minute
Temperature:
36,9c

A
Ruptured of the
tendon of extensor
indices and tendon
of extensor 2nd
digitorum of the left
hand
(ICD X M66.242)

P
Out clinic patient