1 Patient

st
 IDENTITY
• Name : Mr. Joni
• Sex : Male
• Age : 30 y.o
• Occupation : Unemployee
• Medical Record : 01637762
 Primary Survey
Male 61 years old came to the emergency department with chief
complaint pain on her left foot with an corpus alienum.

A: Clear, stable c-spine

B: Spontaneous, thoracoabdominal, RR: 20 x/m
C: HR: 69 x/m, BP : 128/70 mmHg
D: GCS E4V5M6, isochoric pupil (3 mm/3 mm)
E: T : 36,5 C, lesion (+) look at physical examination
 History Taking
• Chief Complaint : Pain on her left foot with open wound and an corpus alienum
History of illness :
4 hours before admission, while working on a construction site, a concrete slab suddenly fell
and hit the patient's left leg. There was no history of fainting, vomiting or seizure. After the
incident, the patient complained of left leg pain that was worse when moved. The patient did not
complain of pain in other parts of the body. By the helper, the patient was brought to the
emergency room of Dr. Moewardi Hospital.
History of past illness :
There was no history of systemic disease
There was no history of Trauma and surgery
Ambulation: Patient could walk without assisted device
Covid Screening:
• Flu-like symptom (-)
• Cough (-)
• Dyspneu (-)
• Dysphagia (-)
• History of Fever (-)
• History of Fatigue (-)
• History of Travelling Out of Town (-)
• History of Contact with Suspect/Probable/Confirmed Covid-19 patient (-)
• Domicile: Palur
• History of Vaccination 2x
 Secondary Survey

Head : no abnormality
Neck : no abnormality
Eyes : no abnormality
Nose : no abnormality
Ears : no abnormality
Mouth : no abnormality
Chest : Excoriation wound at left chest size 1x2 cm
Abdominal : Excoriation wound at left chest size 2x2 cm
Back : no abnormality
Extremities : Lesion (+) look at physical examination
Clinical Appearance
 Physical Examination
Left Lower Leg Region
L : - Corpus alienum iron concrete with a wound on the plantar pedis
penetrating the dorsal side between the web space of PIP digiti I, II and
PIP digiti III, IV with minimal bleeding, iron rust contaminants, swelling
around the wound and unclear deformity
.- Vulnus excoriation size 1x1cm proximal region phalanges digiti 1.
F : There was tenderness on distal of the lower leg, CRT of the 1st – 3rd toes
were >2”, SpO2 of the 1st – 3rd toes were 0%, SpO2 of 1st - 5th toe was
98-100
M : Active ROM MTP, PIP and DIP I,II, III, IV, limited pain
 Physical Examination
Hard Sign
- Absent of pulsation (-) MESS Score
- Severre Hemorhage (+)
- Medium energy (2)
- Expanding Hematome (-)
- Pulsatile Hematome (-) - Systolic BP always > 90
- Audible Bruit / Palpable thrill (-) mmHg (0)
- Pulse reduced or absent but
Soft sign perfusion normal (1)
- Numbness and neurological deficit - Age (2)
(+)
- Difference skin temperature (+)
- Absence of pulse oxymeter reading Total Mess Score : 5
(+)
 1st assessment
Orthopaedi and Traumatology Division
Close Injury of Left Distal Lower Leg Region
DD//
- Close Fracture of Left Shaft Tibia, Distal Third
- Close Fracture of Left Ankle
Open Fracture of Left Foot Region Susp. Open Fracture of 1st – 4th Metatarsal

Cardiothoracic and Vascular Surgery Division

- Susp. Rupture of the Left Dorsalis Pedis Artery

Hypertension Grade I
DM Type 2
 1st Plan
- Inf. RL: Tutosol: Triomix: Kalbamin 1500 ml / 24 hours

- Inj. Tetagam 250 IU- Inj. Ranitidine 50 mg/12 hours

- Inj. Netilmicin 300mg/12 hours

- Inj. Metamizole 1gr/8 hours

- Pedis Immobilization with Spalk

X-Ray Sukoharjo General Hospital
05.09.23
X-Ray Sukoharjo General Hospital
05.09.23
 2nd Assesment
Orthopaedi and Traumatology Division

- Open Fraktur Base Proximal Phalang Digiti III Pedis (S), Transverse Type, Swanso Szabo Anderson Type I (AO:
88.3.2.1B)

- Corpus Alienum Besi Beton Regio Webscape PIP I-II dan PIP III-IV Pedis (S)

- Closed Fraktur Base Distal Phalang Digiti I Pedis (S) , Oblique Type, Minimal Displaced (AO: 88.1.2.3B)
 2nd Plan

- CITO Debridement

- Corpus alienum extraction

- ORIF Base Distal Phalanges Digiti 1 Pedis (S) with Cross Wire

- ORIF Base Proximal Phalanges Digiti 3 Pedis (S) with IM Wire