IDENTITY

Name
: Mr. Aris
Age : 44 years old
Address : Lainea
DPJP
: dr. Tri Tuti Hendarwati, Sp.OT
Admission : Saturday, October 17th 2015

History taking
Chief Complaint: Pain at right hand
Anamnesis:
suffered since 1 week before admitted
to the hospital due to hiitting a man.
Mechanism of trauma, patient hitting
someone's face several times. when
the incident right thumb dental
patients about the person. a few days
later, the patient felt the thumb of his
right hand began to swell and pain.
Finally, the swell already spread to the

Physical examination
GS : Mild ill, Conscious
Vital sign. BP : 130/80mmHg RR: 21 x/mnt
P : 98x/mnt
General state :
Head
Eyes
Ear
Noise
Mouth
Neck
Chest
Abdomen

: no abnormality
: no abnormality
: no abnormality
: no abnormality
: no abnormality
: no abnormality
: no abnormality
: no abnormality

T : 37,1oC

local state (right hand) :

Look: lacerated wound dorsal

digity I, size 2x1cm, no
bleeding, no clean, bullae.
Swelling at right hand
Feel : Felt warm, tenderness (+),
sensibility is good, capillary
refill time < 2
Move : Active and passive
movement of the wrist joints
are limited due to pain

Diagnosed
Acute Osteomielitis at digity I
of right hand
Plan
Plan
diagnosed
diagnosed
Dailyblood
blood
Daily
Planright
right
Plan
hand
hand
AP/Lateral
AP/Lateral

Manageme
Manageme
nt
nt

IVFDRL
RL
IVFD
Analgesic
Analgesic
Antibiotic
Antibiotic
Orthopaedic
Orthopaedic
consult
consult

Thank
You
BAGIAN ILMU ORTHOPAEDIC
Alfaa Fahmi Azizi