Ni Made Febri

Supervisor :Letkol Ckm dr. Basuki Widodo, Sp.OT

Identity

She lived at Ds. Bawang, RT 07 RW 14 Kel. Ngadirejo V, Salaman

AnamnesaChief complaints: The patient came to the Orthopaedic clinic with complaints that the right IV fingers can not be properly right into a straight after flexi in the last 1 month.

History of present illness: the right IV finger pain sometimes when move. Attacks usually occur in the morning until late afternoon, in the night is not come.

Medical history first: 1 year ago had fallen and her fingers slightly curved, and was taken to Sangkal Putung.

Family history of disease: hypertension (-), Diabetes Mellitus (-).

Socio-Economic History: The state of patient socioeconomic well. Patients supported by ASKES, and treated in Ward Edelweis VIP class.

Vital Sign

Blood presurre : 120/80 mmHg

Pulse : 84x/ minute

Temperature : 36 C Respiratory : 24 x/ minute

Physical Examination

HEAD Eye : CA -/- , SI -/- Pupil isocor : 2 milimetres Head Shape : MesochepalTHORAX

Cor : SI dan SII normal regular Pulmo : vesicular, ronkhi -/- , wheezing

-/-

ABDOMENInspection : Symmetrical, flat stomach, sikatrik (-)

Auscultation : Bowel (+) normal

Palpation : tenderness (-),pain off(-), liver and spleen no palpable enlarged

Percussion : Timpani

EXTREMITAS

DIGITI IV DEXTRA

• Look : do not look any deformity

• Feel : pain (-), edema (-), pulse (+)

• Movement : you hear a "click" on the digiti IV dextra when straightened

after flexi

Diagnose

TRIGGER FINGER DIGITI IV MANUS DEXTRA

therapy

Infus RLPremed Broadced 1 G

Operative

PRO RELEASE DIGITI IV MANUS DEXTRA

THERAPY

INFUS RL diganti dengan amino fluid Injeksi Ketorolac 3 x 30 mg Broadced 2 x 1 G (ganti oral)

Vital Sign

Blood presurre : 120/80 mmHg

Pulse : 84x/ minute

Temperature : 36 C Respiratory : 20 x/ minute

DIGITI IV DEXTRA

• Look : there is scar at palmar dextra

• Feel : pain (+), edema (-), pulse (+)

• Movement : flexi movement is not optimal

patient is allowed to go home

THERAPY

CIPROFLOXAXIN 2 X 500 MG ASAM MEFENAMAT 2 X 500 MG Q10DS 2 X 1

22 oktober 2012

Patients come to the Orthopaedic Clinic for control. From the results obtained diagnose that the patient had no complaints, Ring Of Motion (ROM) is good. The patient was able to move his hands, it can be activity as usual, and was able to use his hand to write.