Patient Identity Name : MunardiAge : 27 years oldAddress :
Ds.Prada Kec.Syiah Kuala.Banda Aceh Occupation : EntrepreneurMR :
987881Hp : 08126929471Patient came: 10.00 AM
Chief Complaint Pain and difficulty moving of the right hand
Present illness history The patient came to RSUDZA with a chief
complaint pain and difficulty moving of the right hand since 1 hour
ago. The patient was cutting glass with cutter knife , suddenly the
glass hit his right hand. There was no trauma at the other part of
body
Physical examination Primary Survey Airway : Clear Breathing :
Spontaneous, 20 breaths/min.Circulation : BP: 110/90 mmhg, Pulse :
96 beats/minDisability : GCS E4 V5 M6 : 15Exposure: L/S at the
right forearm L : Wound (+) size 4 x 2 cm , bone exposed (-),
tendon exposed (+) F : Pain (+), NVD (-) M : ROM free
Secondary survey There was no trauma at other part of body
Assessment Ruptured of the flexor tendon at the Zone V at the
right hand.
Laboratory result Hemoglobin : 14,0 gr/dl White Blood Count :
12.700 mg/ ulPlatelets : 204.000/ulHematocrit : 39 %CT/BT :
8/2Blood glucose ad random : 99 mg/dl
Diagnose Ruptured of the flexor tendon at the Zone V of the
right hand. (ICD X M66.20)
Consult to orthopedic divisionDebridement + Exploration and
Repair tendon emergency
Operation Report Patient in supine position with general
anasthesiaAsepsis, antisepsis and drapping procedurePerformed
debridement with NaCl 0,9 %, povidonie iodine and H2O2 Exploration
at the old wound, there was total ruptured of the flexor digitorum
superficialis tendon, palmaris longus tendonPerformed sutured
flexor digitorum superficialis tendon, palmaris longus tendon with
non absorbable 2-0 by Kessler modified procedurePerformed irrigated
with NormosalineWound operation closed by primary suturePerformed
backslab and Kleinert procedure
Post operative diagnoseRuptured of the flexor digitorum
superficialis tendon and palmaris longus tendon at the Zone V of
the right hand (ICD X M66.20)
DateSOAP22-1-2014POD 1pain (-)Vital signBlood pressure : 120/80
mmhgHR : 100 beats/ minuteRR:20 breaths/minuteTemperature: 36,9c
Ruptured of the flexor digitorum superficialis tendon and palmaris
longus tendon at the Zone V of the right hand (ICD X M66.20)IVFD RL
0,9% 20 drips/minutesInj.Ceftriaxon 1gr/12hoursInj. Ketorolac 30 mg
/ 8 hoursInj.Ranitidin 25 mg/12 hours
