Duty Report

(11th Nov 2019)

Wan Nor Syazana

Nur Hayani
 Dokter Jaga Patient
Trauma = 1 patient
dr. Jeffry Non-Trauma = 0 patient
Admitted = 0 patient

Name Age Diagnosis

Mr. VAS 32 yo Open fracture of digiti I-V pedis
dextra, 1/3 proximal of tibia dextra
and 1/3 proximal of fibula dextra
1st case
Identity & History

Name Mrs. N Past Medical History:

Sex Male (-)
Age 32 y/o

Family History:
(-)
Other complaints:
Chief complaint:
- Difficulty in moving right leg due
Pain at the right leg 30 minutes
to pain
before admitted
 HISTORY OF PRESENT ILLNESS

8 o’clock at night, the patient was riding his motorcycle when he was accidentally
hit by a truck container from the right side. He fell and his right leg was dragged
by the truck container. He was brought to the hospital immediately. Due to the
incident, there’s open fracture of digiti I-V pedis dextra, 1/3 proximal of tibia
dextra and 1/3 proximal of fibula dextra. ROM is limited due to pain.
 Biomechanism of Trauma

20:30 pm
20:00 pm
IGD
(before
RSUD
admitted)
IGD Koja

Patient was immediately

brought to RSUD Koja.
Patient complaints
The patient was riding his pain at wound site.
motorcycle when he was
accidentally hit by a truck
container from the right
side. He fell and his right
leg was dragged by the
truck container.
 Primary Survey

Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), cold extremities, BP: 120/86, HR: 82 x/mins, Temp: 36.5 C, CRT <2 sec
Disability :
GCS (E4M6V5) = 15
Secondary Survey

●Head : bleeding (-), swelling (-), tenderness (-), hematoma (-),

●Eyes : eyebrow (-), isokor 3mm/3mm, CA (-/-), SI (-/-)
●Nose : hair nose (-), bleeding (-)
●Ear : normotia, bleeding (-)
●Mouth : mucosa redness, cyanosis (-),
●Neck : enlargement of lymph nodes (-)
Thorax :
• Inspection : Symmetrical
• Palpation : Vocal fremitus & tactile symmetrical
• Percussion : resonance in both lungs
• Auscultation : Vesicular, Rh -/-, Wh -/-; Heart sound I-II normal

Abdomen :
• Inspection : Flat, mass (-),
• Auscultation : Peristaltic sound (+), normoperistaltic
• Palpation : Soft & non tender, distention (-)
• Percussion : Tymphany
 Local state of pedis dextra
• Look: Vulnus avulsi on 1/3 distal
pedis dextra with irregular edge,
6x5cm, base of wound: bone, active
bleeding (+)
• Feel: tenderness (+) pulsation (a.
dorsalis pedis) (+) normal distal
sensory, CRT >2s, SpO2 (not
carried out). Cold extremities.
• Move: Limited ROM of pedis
dextra due to pain. Limited
extension and flexion.
 Local state of ante cruris dextra
• Look: Vulnus laceratum on 1/3
proximal medial ante cruris dextra
with irregular edge, 4x1cm, base of
wound: bone, active bleeding (+)
oily secrete (+), anterior angulation
of 1/3 distal ante cruris.
• Feel: tenderness (+) pulsation (a.
dorsalis pedis) (+) normal distal
sensory, CRT >2s, SpO2 (not
carried out). Cold extremities.
• Move: Limited ROM of cruris
dextra due to pain. Limited
extension and flexion.
Diagnosis and problem

Working diagnosis:
Open fracture of digiti I-V pedis Problems:
dextra, 1/3 proximal of tibia
dextra and 1/3 proximal of fibula • Pain
dextra • Bleeding
Management
NON SURGERY

Pharmacology
SURGERY
Tetagam 250IU
Reconstruction Ketorolac 30mg
OMZ 40mg
Ceftriaxone inj 1gr
Gentamycin 80mg

Non-pharmacology

Bed rest
Wound closure
Splinting