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    Open Fracture Digiti V at Right Pedis

    Uploaded by

    Deei Rizal
    The document summarizes the findings of an initial assessment of a patient who suffered injuries to their right foot in a motorcycle accident. It notes the patient's vital signs, including a temperature of 36.5°C, blood pressure of 130/70 mmHg, and pulse of 92 bpm. On examination of the right foot, there was deformity, swelling, hematoma, and a lacerated wound on the fifth digit with tendon exposure but no bone exposure. X-rays showed an open fracture of the fifth digit. The diagnosis was an open fracture of the fifth digit on the right foot. Management included IV fluids, antibiotics, analgesics, wound care, immobilization and elevation, along with consultation of an orth

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    Open Fracture Digiti V at Right Pedis

    Uploaded by

    Deei Rizal
    28 views11 pages
    The document summarizes the findings of an initial assessment of a patient who suffered injuries to their right foot in a motorcycle accident. It notes the patient's vital signs, including a temperature of 36.5°C, blood pressure of 130/70 mmHg, and pulse of 92 bpm. On examination of the right foot, there was deformity, swelling, hematoma, and a lacerated wound on the fifth digit with tendon exposure but no bone exposure. X-rays showed an open fracture of the fifth digit. The diagnosis was an open fracture of the fifth digit on the right foot. Management included IV fluids, antibiotics, analgesics, wound care, immobilization and elevation, along with consultation of an orth

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    Open Fracture Digiti v at Right Pedis

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    Open Fracture Digiti v at Right Pedis

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    The document summarizes the findings of an initial assessment of a patient who suffered injuries to their right foot in a motorcycle accident. It notes the patient's vital signs, including a temperature of 36.5°C, blood pressure of 130/70 mmHg, and pulse of 92 bpm. On examination of the right foot, there was deformity, swelling, hematoma, and a lacerated wound on the fifth digit with tendon exposure but no bone exposure. X-rays showed an open fracture of the fifth digit. The diagnosis was an open fracture of the fifth digit on the right foot. Management included IV fluids, antibiotics, analgesics, wound care, immobilization and elevation, along with consultation of an orth

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    28 views11 pages

    Open Fracture Digiti V at Right Pedis

    Uploaded by

    Deei Rizal
    The document summarizes the findings of an initial assessment of a patient who suffered injuries to their right foot in a motorcycle accident. It notes the patient's vital signs, including a temperature of 36.5°C, blood pressure of 130/70 mmHg, and pulse of 92 bpm. On examination of the right foot, there was deformity, swelling, hematoma, and a lacerated wound on the fifth digit with tendon exposure but no bone exposure. X-rays showed an open fracture of the fifth digit. The diagnosis was an open fracture of the fifth digit on the right foot. Management included IV fluids, antibiotics, analgesics, wound care, immobilization and elevation, along with consultation of an orth

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 11

    A Clear, Cervical Spine Control

    B Respiratory rate 20x/m, spontaneous, thoracoabdominal type,


    symmetrical, regular

    C Blood Pressure 130/70 mmHg


    Pulse 92 x/m, regular, strong

    Glasgow Coma Scale (E4M6V5), Isochoric


    D pupil, Ø 2.5 mm/2.5 mm, Light reflex +/+, VAS
    5/10

    PRIMARY E Temperature 36,5 OC/Axillary

    SURVEI
    (10.25 am)
    • Chief complain : Pain at right foot on fifth finger
    History Taking
    Suffered since ± 4 hours ago due to traffic accident.
    Mechanism of trauma :
    Patient was ride a motorcycle, he was use helmet with moderate speed. Suddenly, he
    felt down to the right side when he try to avoid the other motorcycle.
    • There was no history of syncope, nausea and vomiting
    • There was no history of drugs or alcohol consumption
    • There was no previous treatment

    Anamnesis
    (10.30 am)
    SECONDARY SURVEI (10.35 am)

    GENERAL STATE Composmentis, moderate illnes, good nourish

    Vital Sign
    BP : 120/70 mmHg
    HR : 80x/minute, regular, strong
    RR : 18x/minute, regular, symmetrical
    T : 36,5◦C/axillary
    VAS : 4/10
    STATUS PRESENT

    Head : Within Normal Limit Neck : Within Normal Limit


    Face : Within Normal Limit Chest : Within Normal Limit
    Eyes : Within Normal Limit Abdomen : Within Normal Limit
    Nose : Within Normal Limit Upper limb : Within Normal Limit
    Mouth : Within Normal Limit Lower limb : Localized state
    Ears : Within Normal Limit
    • Right Pedis Region

    I : Deformity (+), swelling (+) at digiti -V , hematoma (+), wound (+)


    Lacerated wound at digiti V, size 2 cm x 1 cm , with irregular edge, bone
    expose (-), tendon expose (+)

    P : Tenderness (+)

    ROM : Active and passive movement at metacarpophalangeal and


    interphalanx joint 5 finger limited due to pain

    NVD : good sensibility, CRT <2 Seconds

    LOCALIZE STATE
    Clinical Finding
    Routine Blood
    X-Ray Right Pedis AP/Oblique

    Planning Diagnostic :
    X-Ray Right Pedis AP/Oblique
    Open Fracture Digiti V at Right Pedis

    DD/
    • Dislocation of interphalangs distal joint digiti V at Right Pedis

    • Rupture Tendon digiti V at Right Pedis

    DIAGNOSIS
    PHARMACOLOGY NON PHARMACOLOGY
    • Wound care
    • IVFD
    • Rest
    • Antibiotic injection • Immobilization
    • Analgetic injection • Elevation
    • H2RA injection

    Consult Orthopedic Surgeon

    MANAGEMENT

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