List Ruangan Angsoka

KAMAR/MRS IDENTITAS DIAGNOSIS TERAPI PLANNING PRE/POS

NO T OP
1 Angsoka Sultani Traumatic Amputation of Right Forearm Rawat Luka Debridement + Pre OP
101.2 M/43 y.o ec Blast Injury Skin Graft kp BRM
08-08-16 BPJS Combution gr II AB 6 % Left Thigh Flap
HAND + 16031821 Combutiom fr III 2 % of Right Femur
PLASTIC Post Debridement (27/07/16)
2 Angsoka Andri Ayudi CF Left Femur Middle Third ORIF PS Pre OP
108.1 M/26 y.o CF Right Galeazi
LOWER + Umum
HAND 16037531
30-08-16

4 Angsoka Komang Sadia Fr. 5th, 6th and 7th Posterior Ribs, 8th and 9th ORIF PS Pre OP
106.2 M/60 y.o Lateral Ribs of Right Hemithorax (acetabulum) BRM
HAND + JKBM Old Fracture CV Th XII Frankel E Tunggu CT Scan
LOWER 16035193 CF Right Distal Radius Frykman VII Post Pelvis dan X
16-06-16 Immobilisation with LAC Ray Wrist
CF Right Acetabulum
CF Right Ramus Pubis Superior
 List Ruangan Luar Angoka
NO KAMAR/MRS IDENTITAS DIAGNOSIS TERAPI PLANNI NOTE
NG
1 WK Ketut Implant Expose et causa ORIF PS Tibia AB Post OP
25-8-16 Kuryawan Fibula Sinistra Post Debridement + VAC Analget BRM
HAND M/65 yo ic
16034278
BPJS
2 ICU Barat Nengah Trauma Tumpul Abdomen Post Laparotomy X-Ray Pre OP
HAND + Munduk CF Distal Radius Dextra et Sinistra Post bila YAS
TRAUMA M/50 y.o Immobilization with Backslab kondisi
20-08-16 JKBM baik
16036070
3 IGD Putu Yudi V. App Frontal AB Post OP
HAND + Ardanaya Fr. Maxilla Cominutive D Analget YAS
TRAUMA M/32 y.o CF Left Clavicle Lateral Third ic
26-08-16 BPJS CF Left Humerus Middle Third
16037161 Post ORIF PS (Humerus)
NO KAMAR/MR IDENTITAS DIAGNOSIS TERAP PLANNI NOTE
S I NG
4 RR IGD Budiharta Vulnus Appertum left Antebrachii region Post OP
HAND Dewa Ketut Left Flexor tendon Injury Zone V (Rupture
30-08-16 M/48 y.o of Left 3rd -5th FDP FDS)
16031821 Rupture Artery Ulnaris
BPJS Post Debridement + Exploration +
Tendon Repair + Vascular Repair

5 UGD Abdullah Moderate head injury (S09.90) ORIF PS Pre Op

HAND Male/39 y.o
Skull Base fracture (S02.113S)
31/8/2016 16037745
UMUM ICH Left Frontobasal (S06)
Fr. Left Rima Orbita Superior (S02)
Fr. Linear Left Frontotemporal (S02.3)
CF Shaft 3rd-5th Left Metacarpal (S62
6 UGD Mr.X Moderate head injury (S09.90) Debridem Pre Op
HAND Male/29 y.o. ent +
Brain Swelling (S06)
31/8/2016 16037903 ORIF PS
Umum Fracture Symphisis Mandibula (S02.6)
Fracture Processus Alveolaris (M26
OF Right 4th Shaft MC (S62.3)
Open Wound Ring Finger Right Hand
Identity
Name : Sultani
Sex : Male
Age : 43 y.o.
CM : 16031821
Payment : Umum
Admitted : 26-7-16
Ward : Angsoka 1
 History

Conscious patient complained pain on his right arm, chest and

right thigh since 1 days prior to admission.
He was working as engineer when a machine exploded.
History of unconscious (-), nausea and vomit (-).
Patient was referred from Singaraja Hospital with V. Amputatum
Right Arm Distal third + Combustio region chest and leg
Right Forearm Region
L : traumatic amputation of right arm, 20 cm distal to olecranon, bone exposed (+), muscle
expose (+), tendon expose (+), vascular expose (+) nerve expose (+). Necrotic (+) on distal
part volar side. Active bleeding (-)
F : Hipoastesia (+) distal of elbow , a. brachialis pulse (+)
M : Active ROM Elbow limited due to pain
Active ROM Shoulder Flexion Extension 300 0 1800
Active ROM Shoulder Abduction Adduction 180 0 0 - 1200
Lower Extrimity Region
L : Combution on antero lateral side of right and left thigh size 15x20 cm grade III, muscle expose (+),
tendon expose (-), bone expose (-), necrotic tissue (+), deformity (-), combustion of left thight
F : Tenderness around the wound, CRT <2, a. dorsalis pedis pulse (+) on right and left sside
M : Active ROM Right Hip limited due to pain
Active ROM Left Hip 0/110
Active ROM Right Knee Limited due to pain
Active ROM Left Knee 0/120
Right Forearm X Ray AP/Lateral View
Diagnosis :
Traumatic Amputation of Right Forearm ec Blast Injury
- Open Fracture radius distal third
Combution grade IIAB 6% of Chest and Left Thigh
Combution grade III 2% of Right Femur

Treatment :
Analgetic, Antibiotic, Antitetanus
Debridement + Open amputation of Right Forearm until the level of
viable soft tissue
Debridement Combution
P/ Observation for sign of infection and demarcation
Closure Stamp
Combution wound care (plastic surgery)
Clinical Post Op
Clinical August
Clinical August
 Identity

Name : Andri Ayudi

Sex : Male
Age : 26 y.o
Address : Denpasar
CM : 1637531
Insurance : BPJS
Admitted : 29-08-16
Ward : Angsoka 1
 History
Conscious patient complained pain on his left thigh and right forearm
after had traffic accident 2 hours prior to admission.
Patient rode motorcycle, hit by a car on the left side, and then patient
fall down with left thigh and right hand bump to the ground
History of unconciousness (-), nausea (-), vomiting (-).
Patient was referred from Wangaya General Hospital by Orthopaedic
Surgeon diagnosed with CF left femur middle third and CF right radius
distal third
Right Forearm-Wrist Region
L : Swelling (+) distal third forearm, Bruise (-), deformity (+) valgus
angulation, prominent distal ulna
F : Tenderness (+) over the wrist and distal third radius, crepitation distal third
radius, piano key sign (+) radialis artery pulse (+) palpable, CRT < 2
M : Active ROM Wrist (+) limited due to pain
Active ROM MCP-IP 0/90
 LLD D S
1 cm

FL 80 79

AL 76 75

Left Thigh Region

L : Swelling (+) over the middle third, deformity (+) shortening and
external rotation
F : Tenderness (+) over the middle third, crepitation (+) when
applied splint,
CRT < 2 , pulse of dorsalis pedis artery palpable
M : Active ROM Knee limited due to pain
Active ROM Ankle (+) 35/45
Active ROM MTP-IP (+) 45/90
Right Forearm X-ray AP/ Lateral View
Left Femur X-Ray AP/Lateral View
Diagnosis
Closed Fracture Right Galeazzi
Closed Fracture Left Femur Middle Third
Treatment
Analgetic
Closed reduction + Immobilization with LAC
Immobilization Skin traction 5kg load
P/ ORIF P-S (Femur + Radius)
 Clinical Picture
(Post Closed Reduction + Immobilization
with LAC)
Identity
Name : I Made Widiadnyana
Sex : Male
Age : 28 y.o.
CM : 16037212
Payment : BPJS
Admitted : 27-7-16
Ward : Angsoka 1
History
Conscious patient complained of pain and open wound on his left
forearm after had traffic accident 3,5 hours prior to admission.
Patient was a passenger in the car, suddenly the car was avoided
the truck from the front to the left side with his left forearm hit
over the tree
History of unconciousness (-), nausea (-), vomiting (-).
Patient was referred from Karangasem General Hospital by General
Surgeon had diagnosed with OF left forearm
Left Forearm Region
L : Swelling (+) over the forearm, multiple v. app + open wound 2X3 cm at
dorsal side, bruise (+), deformity (+) dorsal angulation, bone Expose (+) at
ulnar site, Muscle expose (+).
F : Tenderness (+) shaft to distal forearm, crepitation when splint applied, a.
radialis pulse (+) palpable, CRT < 2, SaO2 96-97%, sensation (+) normal
M : Active ROM Elbow Limited due to pain
Active ROM Wrist (+) limited due to pain
Active ROM MCP-IP digits 45/90
Left Antebrachii X-Ray AP/ Lateral View
(Sanglah Hospital)
Left Wirst X-Ray
AP/Lateral
Diagnosis :
Malunion Fracture of left distal radius
OF Left Montegia gr II Bado type 3

Treatment :
Debridement + ORIF P-S + Backslab
 Left Forearm X-Ray Post Op View

Pre Op Post Op
Clinical Post Op
Clinical Post Op with
Backslab
 Identity

Name : I Komang Sadia

Sex : Male
Age : 65 y.o
CM : 16035193
Payment : JKBM
Admitted : 15-08-16
Ward : MS 207A
 History
Conscious patient complain pain on his right wrist and pelvic after had
accident 5 hours prior to admission.
Patient tried to fix the roof, slipped and he fell down with his right wrist
and pelvic bumped to the ground.
History of unconsciousness (-), nausea (-), vomitting (-)
Patient refered from Karangasem General Hospital by General Surgeon
with diagnosis CF right Acetabulum + Ramus Pubis, CF distal radius D.
History of trauma (+) :
15 years ago, Patient was fall from 4 m height and impact to his
backbone. Heal (+) Bonesetter (+), No complain with her back and lower
leg after the injury. He can walk normaly until now.
Right Wrist Region
L : Swelling and bruise at wrist, Deformity (+) dorsal angulation
F : Tenderness (+) at radial side , crepitation (+) when splint applied, a.
radialis palpable, CRT < 2, SaO2 99%, sensation (+) normal
M : Active ROM Wrist Limited Due to pain
Active ROM MCP IP 0/90
 Motoric Evaluation
D Muscles S
5 Elbow flexor 5
Limited Wrist extensor 5
due to
pain
5 Elbow extensor 5

5 Finger flexor 5
5 Finger abductor 5

Limited Hip flexor 5

Lumbar Region due to
L: Swelling (-) ,bruise (-) pain
5 Knee extensor 5
F : Tenderness (-), hipoesthesia (-)
5 Ankle 5
dorsoflexor
5 Toe extensor 5
5 Ankle 5
Plantarflexor
Pelvic region
L : Swelling (+) at right hip region, bruise (-) no deformity
F : Tenderness (+) at right hip, a.dorsalis pedis (+) palpable, CRT <
2, SaO2 99%, sensation (+) Normal
M : Active ROM Right hip limited due pain
Active ROM knee limited due to pain
Active ROM ankle 30/40
Active ROM MTP-IP 0/90
Chest X ray AP View
Thoracolumbal X ray AP/Lateral
View

KOA : 30
LOH : 20
Pelvis X ray AP View
Pelvis X ray AP View

Alar X Ray View Obturator X Ray View

Right Wrist X-ray AP/Lateral
View

Radial Inclination
: 18oo
Radial Length
: 11 mm
Dorsal Tilt
: 25oo
 Diagnosis:
Fr. 5th-7th Posterior Ribs, 8th-9th Lateral Ribs of Right Hemithorax
without complication
Old Fracture CV Th XII Frankel E
CF Right distal radius Frykmann VII Cominutive
CF Right Acetabulum :
Anterior wall
Anterior Collum
CF Right Ramus Pubis Superior

Treatment:
Trauma :
Conservative

Orthopaedi :
Analgetic
Closed Reduction under GA with Immobilisation Long Arm Cast (Wrist)

Immobilisation with skin traction, load 5 kg (Right Femur)

P/ ORIF PS (Elective) Acetabulum
 Right Wrist X ray AP/ Lat View
Post LAC

Radial Inclination : 18 Radial Inclination : 20

Radial Length : 11 mm Radial Length : 12 mm
Dorsal Tilt : 25 Volar Tilt : 5
Clinical Post Reduction
Identity
Name : dr. Lato Kartiko Wibowo
Sex : Male
Age : 33 y.o.
CM : 16036905
Payment : BPJS
Ward : Angsoka 1
Admitted : 26-08-16
History
Conscious patient complained pain over his right elbow
after fell down 4 days ago
He was fixing a lamp in his house, suddenly fell from a
chair with his right elbow bumped to the floor.
History of unconsciousness (-), nausea (-), vomitting (-)
Patient was referral from Siloam Hospital by
Orthopaedic Surgeon With Diagnose CF Right Radial
Head
Right Elbow Region
L : Swelling (+) at the lateral side of elbow, deformity (-)
F : Tenderness around the elbow, A. Radialis (+) palpable,
paresthesia (-), CRT < 2, SaO2 99%
M : Active ROM Elbow Limited due to pain
Active ROM Wrist 80/70
Active ROM MCP IP 0/90
Right Elbow X-Ray AP/Lateral View
Right Elbow CT-Scan
Clinical Post OP
 Identity

Name : Adelia
Sex : Female
Age : 16 y.o
Address : Denpasar
CM : 15058921
Insurance : BPJS
Ward : 081916128587
 History
Patient complaint pain around her
left shoulder since a month ago.
She had history of surgery ORIF PS
because of clavicle fracture 8 months
ago at Sanglah Hospital
Left Shoulder Region
L : Post op scar (+) Implant Protrusion (-)
F : Tenderness (+) ,CRT <2, Radial artery (+) palpable
M: Active ROM Shoulder normal
Active ROM wrist 30/45
Active ROM MCP-IP 0/90
Left Shoulder X-Ray AP View
Diagnosis
Union Left Clavicle

Planning
Implant Removal
Clinical Post OP
 Identity

Name : Ketut Kuryawan

Sex : Male
Age : 65 y.o
CM : 16034278
Payment : BPJS
Address : Singaraja
Phone : 081246425314
History

Patient complaint about post operative wound at his left leg that did
not heal properly.
Patient had history of surgery ORIF PS because of Open Fracture at his
Right Leg 2 months ago at Buleleng Hospital
Patient was referred by Orthopaedic Surgeon to Sanglah Hospital with
diagnose Implant Exposed et causa OF Left Leg Post ORIF PS
Left Leg Region
L : Wound (+), Implant expose (+)
F : Tenderness (+), a. dorsalis pedis (+), SaO2 98-99%
M : Active ROM Ankle 20/40
Active ROM MTP-IP 0/90
Left Leg X-ray AP/Lateral View
Diagnosis:
Implant Exposed Et Causa Open Fracture Right Leg Post ORIF PS

Planning :
Debridement
Durante OP
Clinical Post OP
Clinical Post OP
 Identity

Name : Nengah Munduk

Sex : Male
Age : 50 y.o
Address : Klungkung
CM : 16036070
Insurance : JKBM
Admitted : 20-08-16
History
Concious patient complained pain in his stomach, right and left wrist
after fell down 5 hours prior to admission .
Patient was climbing a tree then fell down with his hands withstand
body, his stomach bumped to ground
History of Unconcsiousness (+), nausea (-), vomitting (-)
Patient was referred from Karangasem Hospital by General Surgeon
with Susp Abdominal Blunt Trauma + Susp CF Left and Right Distal
Radius . Patient was already given Fluid Resuscitation 2 L
Right Wrist Region
L : Swelling (+) over the distal part, Deformity (+) Dorsal Angulation
F : Tenderness (+) at distal part, Crepitation (+) when apply splint, A.
Radialis ( +) palpable, CRT > 2, SaO2 99%,
M : Active ROM Wrist limited due pain
Active ROM MTP IP 0/90
Left Wrist Region
L : Swelling (+) over the distal part, Deformity (+) Dorsal Angulation
F : Tenderness (+) at distal part, Crepitation (+) when apply splint, A.
Radialis( +) palpable, CRT > 2, SaO2 99%,
M : Active ROM Wrist limited due pain
Active ROM MTP IP 0/90
Cervical X-Ray Lateral View
(Karangasem Hospital)
 Chest X-Ray AP View
(Karangasem Hospital)
Pelvis X-Ray AP View (Karangasem
Hospital)
Laboratory (20/8/16)
Karangasem Hospital
11.00 12.00

18 Result Norm Result Norm

al al
WBC 31.5 6,0- WBC 23.7 6,0-
17,0 17,0
HB 12.4 12-16 HB 9.11 12-16
HCT 37.2 36-46 HCT 27.7 36-46
PLT 225 150- PLT 190 150-
400 400
 Durante OP

Laparotomy Exploration
Hepar rupture segment II and III Packing
Spleen rupture Gr 4 Splenectomy
Hematome Zona 2 Right And Left
Hematome Zona 1
Bleeding durante op 1.5 L

Post OP Condition
GCS under Drug Influence
BP 100/60 mmHg , PR 98x/mnt
RR on ventilator 13 x/mnt
Post op ICU
 Diagnose:
Hepar Rupture segment II and III post Laparotomy-exploration+Packing
Spleen Rupture Gr IV post Laparotomy - exploration + Splenectomy
Hematome Zona 2 Right And Left
Hematome Zona 1
Suspect CF Right Distal Radius Third
Suspect CF Left Distal Radius Third

Treatment:
Trauma
Optimalized condition at ICU
P/ remove packing 2 days post op
Splenectomy (Spleen)

Orthopaedic
Immobilization with Backslab (Right And Left Forearm)
P/ Left and Right Wrist X-Ray AP/ Lateral (If Patient Stable)
Clinical Post Back Slab
Identity
Name : Pt Yudi Ardanaya
Sex : Male
Age : 32 y.o.
CM : 16037161
Payment : BPJS
Admitted : 26-7-16
Ward : IGD
 History

Conscious patient complained pain on his face, left shoulder and

arm and after had traffic accident 1 hour prior to admission.
Patient was riding motorcycle suddenly slipped and fell down with
his face and left shoulder and arm bumped the ground
History of unconsciousness (+), nausea (-), vomitting (-).
Left Shoulder Region
L : Swelling (+) over the shoulder, bruise (-)
F : Tenderness (+) at the lateral side of shoulder, A. radialis palpable,
CRT<2
M : Active ROM shoulder limited due to pain
Active ROM Elbow limited due to pain
Active ROM Wrist 70/80
Active ROM MCP-IP 0/90
Left Arm Region
L : Swelling (+) over arm , bruise (-)
F : Tenderness (+) over arm, crepitation (+) when applied splint, false
movement (+),
A. radialis palpable, CRT < 2, hypoesthesia (-)
M : Active ROM Elbow limited due to pain
Active ROM Wrist 70/80
Active Thumb Extention (+)
Head Ct-Scan
Left Shoulder X Ray AP View
Left Arm X Ray AP/Lateral View
 Left Humerus X ray AP/Lateral View
(Immobilization U-Slab)

Pre closed reduction Post closed reduction

Angulation Angulation
AP:13 Ap:5
Lat:22 Lat:8
Clinical Picture Post U-Slab
Diagnosis

Mild Head Injury

Fr Comminutive Right maxilla

CF Left Clavicle Allman Type 2

CF Left Humerus Middle Third

Treatment

ORIF Miniplate
ORIF PS (Humerus)
Left Arm X Ray AP/Lateral View
Post OP
Clinical Post OP
Identity
Name : Ni Ketut Sendi
Sex : Female
Age : 57 y.o.
CM : 16037309
Payment : BPJS
Admitted : 28-7-16
Ward : RR IGD
 History
Conscious patient complained of pain on her left arm after hit by a
truck 2 hours prior to admission.
Patient rode motorcycle, suddenly the truck in front of her loose the
break and directly hit the left side of her body when tried to evade
collision.
History of unconciousness (-), nausea (-), vomiting (-).
Patient was referred from Badung Hospital by Orthopaedic with
diagnosis OF Left Humerus
Left Arm Region
L : Swelling (+) over the proximal arm, bruise (+) , Open wound 20x5 cm at the anterior
side with muscle exposed (+), bone exposed (+), fat bubble (+), active bleeding (+)
F : Tenderness (+) over the proximal arm, crepitation (+) when aplied splint, Sat O2:
Thumb , Index, Middle, Ring finger, Little finger 98 %,
CRT thumb little finger < 2 , a. radialis pulse (+), parasthesia (-)
M : Active ROM elbow 130/0/10
Active ROM wrist 80/70
Active ROM MCP-IP 90/45, thumb extension (+), OK sign (+)
Left Arm X-ray AP/Lateral View
Diagnose
OF Left Humerus Middle Third grade IIIA

Treatment :
Debridement and External Fixation
Left Arm X-ray AP/Lateral View Post OP
Clinical Post Op
 Identity

Name : I Nyoman Nutun

Sex : Male
Age : 54 y.o
CM : 16037617
Payment : BPJS
Admitted : 30-08-16
Ward : IGD
 History

Conscious patient complained pain on his head,

face and left wrist 3 hours prior to admission.
Patient was riding a motorcycle suddenly
slipped and fell down with his head, face, and
his hand bumped to asphalt
History of unconscious (+), nausea (-), vomiting
(-)
Patient reffered from Penta Medika Hospital
with Mild Head Injury + CF Left Distal Radius
Left Wrist
L : Swelling (+), Bruise (+), deformity (+) dorsal angulation,
F : Tenderness (+) at volar and dorsal site, a.radialis (+) palpable, CRT <
2, paresthesia (-)
M : Active ROM Wrist (+) limited due to pain
Active ROM MCP-IP 0/90
Head CT-Scan
Head CT-Scan
3D recont
Right Wrist X ray AP/ Lat View

R.Inclination : 20
R.Inclination: 10
Volar Tilt: 8
Diagnosis:
Mild head injury
Brain Swelling
CF Left Maxilla
CF Left Periorbital
CF Left Zygoma Segmental
CF Left Dorsal Barton
CF Left Trapezium
Left Lunate Dislocation

Treatment:
NS:
Conservative
Trauma:
P/ ORIF Miniplate

Orthopedi:
Analgetic
Closed Reduction with GA + Immobilization with SAC + Thumb
Spica cast family refused
Closed Reduction with LA + Immobilization with SAC + Thumb
Spica cast
 Right Wrist X ray AP/ Lat View
Post SAC

R.Inclination : 20 R.Inclination : 19
R.Length : 10 R. Length : 10
Volar Tilt :8 Volar Tilt :7
Clinical Picture Post LAC
Identity
Name : Wayan Neka
Sex : Male
Age : 53 y.o.
CM : 16034065
Payment : BPJS
Admitted : 30-8-16
Ward : IGD
 History
Unconscious patient bring to ER after had a
accident 8 hours prior to admission.
Patient was climb up the stairs suddenly slipped
and fell down to left side with his head bumped to
the floor
History of consciousness (+), nausea (-), vomiting
(-)
Patient was referred from Karangasem General
Hospital with diagnose Deteriorated Mild Head
injury + Fracture costae 3rd , 4th ,5th ,6th with Left
Hemithorax
Left Shoulder Region
L : Swelling (+) over the clavicle lateral third area, skin tenting
(-), bruise (+),
F :Tenderness (+) cant be evaluated, a. radialis (+) palpable,
CRT<2
M: Active ROM Shoulder cant be evaluated
Active ROM Elbow cant be evaluated
Active ROM Wrist cant be evaluated
Active ROM MCP-IP cant be evaluated
Cervical X Ray Lateral view (Karangasem
Hospital)
Head CT Scan
Left Shoulder X Ray AP View
Chest X Ray AP view
Injury Severity Score (ISS)

Head & Neck Moderate Head Injury 3

Face -

Chest Right Pneumothorax 3

Left Hematothorax

Abdomen -

Extremity CFLeft Clavicle 2

External No injury -

ISS =18
Diagnosis:
Polytrauma
Moderate Head Injury
Right Pneumothorax post Thoracostomy WSD
Left Hematothorax post thoracotomy WSD
Fracture 3rd , 4th Ribs Left Posterior Hemithorax
Fracture 5th ,6th Ribs Left Lateral Hemithorax
CF Left Clavicle Lateral Third Allman type II

Treatment
NS : Conservative
Trauma:
Consult to intensive, observation of respiratory distress
Ortho:
Conservative
Immobilization with arm sling when mobilized
Identity
Name : I Dewa Ketut Budiharta
Sex : Male
Age : 48 y.o.
CM : 16031821
Payment : Umum
Admitted : 26-7-16
Ward : Angsoka 1
 History

Conscious patient complained pain on his left

Forearm after accident 1 Hour prior to
admission
Patient was jumping a locking door then his left
forearm suddenly slash by an iron sheet
History of unconscious (-), nausea (-), vomiting
(-)
Patient reffered from Siloam Hospital with wide
V.Appertum Left Antebrachii region + Susp.
Rupture Artery + Rupture Tendon
Left Forearm Region
L : Open wound 7x2 cm at the volar side with muscle exposed (+), Active bleeding (+), tendon
exposed (+),
bone exposed (-)
F : Tenderness (+), CRT < 2 , a. radialis (+) palpable, a. ulnaris unpalpable, sensoric normal,
Sat O2 98%
M : Active ROM Wrist limited due to pain
Active ROM Flexion 1st-2nd PIP Joint (+)
Active ROM Flexion 3rd-5th PIP Joint (-)
Active ROM Flexion 3rd-5th DIP Joint (-)
Left Forearm X Ray AP/Lateral view (Siloam
Hospital)
Diagnose
Vulnus Appertum left Antebrachii region (S01.501)
Left Flexor tendon Injury Zone V (Rupture of Left 3rd -5th FDP
FDS) (M66.9)
Rupture Artery Ulnaris (I77.2)

Treatment :
Analgetic, Antibiotic, Antitetanus
Debridement + Exploration + Tendon Repair + Vascular
Repair
Palmaris Longus
Nervus Rupture
Ulnaris artery ulnaris
Identity
Name : Abdullah
Sex : Male
Age : 39 y.o.
CM : 16037745
Payment : BPJS
Admitted : 31-8-16
Ward : UGD
HISTORY
Unconscious patient has brought to ER after got traffic accident 1
hours (31/8/2016) prior to admission.
Patient was riding a motorcycle suddenly had a crash with
unknown mechanism.
History of conciouss (-)nausea (-), vomitting (-).
The patient was referred by Siloam general hospital by GP
Diagnosed with Moderate Head injury + Skull base Fracture + CF
Left Metacarpal
Left Hand Region
L : Bruise and swelling (+) over the dorsum manus, deformity (-)
F : Souffle, tenderness cant be evaluate, crepitation (+) 3 rd-5th
metacarpal area, CRT < 2, radialis artery pulse (+) palpable, SaO2
98%
M : Active ROM MCP-IP cant be evaluated
Head CT-Scan View
Head CT-Scan View
Skull 3D Recon
Cervical X-Ray Lateral View
Left Hand X ray AP/ Oblique View
Diagnosis
Moderate head injury (S09.90)
Skull Base fracture (S02.113S)
ICH Left Frontobasal (S06)
Fr. Left Rima Orbita Superior (S02)
Fr. Linear Left Frontotemporal (S02.3)
CF Shaft 3rd-5th Left Metacarpal (S62)

Treatment
P/ ORIF PS (elective)
Clinical Post Immobilization with Lumbrical Cast
Identity
Name : Mr.X
Sex : Male
Age : 29 y.o.
CM : 16037903
Payment : BPJS
Admitted : 31-8-16
Ward : UGD
History
Unconscious patient has brought to ER after got traffic accident 2
hours (31/8/2016) prior to admission
Patient was riding a motorcycle suddenly had a crash with
unknown mechanism.
History of consciouss (-), nausea (-), vomitting (-).
Right Hand Region
L : Bruise and swelling (+) over the dorsum manus, open wound 2x1 cm
at MC region, open wound over the ring finger 3x5 cm, deformity (-)
bone exposed (-), tendon exposed (+), active bleeding (-)
F : Tenderness cant be evaluated, crepitation (+) at 4th metacarpal, CRT
< 2, radialis artery pulse (+) palpable
M : Active ROM MCP-IP cant be evaluate
Head CT-Scan View
Head CT-Scan View
Skull 3D Recon
Cervical X-Ray Lateral View
Right Hand X ray AP/ Oblique View
Diagnosis
Moderate head injury (S09.90)
Brain Swelling (S06)
Fracture Symphisis Mandibula (S02.6)
Fracture Processus Alveolaris (M26
OF Right 4th Shaft MC (S62.3)
Open Wound Ring Finger Right Hand

Treatment
P/ Debridement ORIF Miniplate
WTHT + Closed Reduction + Immobilization with Ulnar Gutter