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