SURGERY DEPARTMENT

EMERGENCY ROOM
BAHTERAMAS GENERAL HOSPITAL
KENDARI

Akbal Nur Karim, S. Ked

K1A1 12 021

CASE
REPORT Rupture Tendon Digiti III, IV, V Manus Sinistra
Vulnus Laceratum wrist Joint Sinistra
 Name : Mr. T
Age : 54 years old
Address : Lalonggasu Village
Occupation : Civil Servant
Admission : December, 23th 2018
Doctor in Charge : dr. Muh. Rizal Alisi, Sp.OT

IDENTITY
 A Clear, Cervical Spine Control

B Respiratory rate 18x/m, regular, spontaneous,

thoracoabdominal type, symetris

C Blood Pressure 130/80 mmHg

Pulse 78 x/m, regular, strong

D Glasgow Coma Scale (E4M6V5), Isochoric

pupil, Ø 2.5 mm/2.5 mm, Light reflex +/+

PRIMARY E Temperature 36,5 OC/Axillary

VAS 6/10
SURVEY
(20. 30 )
Chief complain : Wound at the left forearm
History Taking
Suffered since ± 4,5 hours ago before admission to the hospital due to work
accident.
Mechanism of trauma : : Patient was cutting a grass with his machette, and then
accidentally his left hand was chopped with his machette.
• There was no history of syncope and vomiting
• There was no history of drugs or drink alcohol
• There was a dominant right hand
• Prior treatment at primary health care

Anamnesis
(20. 40 )
 Secondary Survey
(20. 50 )

GENERAL STATE
Moderate Illness, Compos mentis, underweight

Vital Sign
BP : 90/60 mmHg
HR: 76x/minutes
RR : 20x/minutes, regular, strong
T : 37,9◦C
VAS : 6/10
 PRESENT STATE
Head : Within Normal Limit Neck : Within Normal Limit
Face : Within Normal Limit Chest : Within Normally
Eyes : Within Normal Limit Abdomen : Within Normally
Nose : Within Normal Limit Upper limb : Localized state
Mouth : Within Normal Limit Lower limb : Within Normal Limit
Ears : Within Normal Limit
 • Left Antebrachial Region
I : Deformity (-), swelling (-), hematoma (-), Lacerated wound, size 4,5 cm x
0,6 cm x 0,4 cm, Bone expose (-), Tendon Expose (+). active bleeding (+)
P : Tenderness (+).

ROM : active and passive movement limited, especially at three finger

(digiti III, IV, V) was drop and active extension was not.

NVD : good sensibility

good capillary refill

LOCALIZE STATE
(FACIALIS REGION)
Clinical Finding
Clinical Finding
 Routine Blood

Planning Diagnostic :
 DIAGNOSIS
Rupture Tendon at left finger 3th,4th, 5th
+
Lacerated wound at left wrist Joint

Differential Diagnosis:
- Fracture Bone Carpal at left hand
- Fracture Bone Metacarpal 4th , 5th at left hand
 PHARMACOLOGY NON PHARMACOLOGY
• Wound care
• IVFD
• Rest
• Antibiotic injection
• Immobilization
• Analgetic injection
• Elevation
• H2RA injection
• Education

Consult Orthopedic Surgeon

MANAGEMENT