C/Male/60yo

Chief Complain : Lacerated wound on the

left foot
The wound has been suffered by the patient since 1
hour before admitted to Pirngadi General Hospital.
Previously, patient had a motorcycle accident that
caused his foot hit the parts of his motorcycle.
Patient wore a helmet and was awake on the time
of the accident, and remembered all of the event.
History of nausea and vomiting was not found.
Active bleeding was not found. History of
immunization was unclear. Patient directly taken to
Pirngadi Hospital.
 AMPLE
• Allergic : No history of Allergy
• Medication : No history of Medication
• Past Illness: No history of past illness
• Last Meal : 5 hours before accident
• Environment : Road
 Present State
Sens: Compos Mentis
HR : 98 beats per minute
RR : 18 times per minute
T : 36,6 C
SpO2 : 98% (Room Air)
VAS : 3
 Generalized State
Head : No abnormality was found
Neck : No abnormality was found
Chest : No abnormality was found
Abdomen : No abnormality was found
Genitalia : Male, no abnormality was found
Upper Extremities: No abnormality was found
Lower Extremities : In localized State
 Localized State

Lower Extremities :
(L) Foot :
• Look : Lacerated wound o/t left
dorsal foot with size 1.5x1x0.5
cm, irregular edge, subcutis
based, contamination (+), active
bleeding (-), erythema (-), bruise
(-), swelling (-), deformity (-)
• Feel : Crepitation (-),
tenderness(-), dorsalis pedis
artery (+)
• Move :
A/PROM on 1st finger:Normal
A/PROM on ankle :Normal
Foot X-Ray
Working Diagnosis
Lacerated wound o/t (L) Foot

Plan
Wound Toilet + Primary Suture
ATS Injection
 Treatment at the Emergency Room
TIME
17.30 Injection of Anti Tetanus Serum 1500 IU IM
Analgetic  Paracetamol 500 mg per oral
Antibiotic Cefadroxil 500 mg per oral
17:40 Radiology Test
18:00 Wound Toilet + Primary Suture
At the Emergency Room

• Patient in supine position, under local

anaesthesia, aseptic antiseptic procedure was
performed.
• Identification of the wound, there was
Lacerated wound o/t left dorsal foot with size
1.5x1x0.5 cm, irregular edge, subcutis based,
contamination (+), active bleeding (-),
erythema (-), bruise (-), swelling (-),
deformity (-)
• Wound was rinsed with normal saline
repeatedly until clean
• All debris and non viable tissue were
removed
 At the Emergency Room
• Refreshed the edge of the
wound until found bleeding,
approximation without
tension.
• Cutis was sutured using
non-absorbable
multifilament material 2.0
cutting bodied with simple
interrupted sutured.
• Operation was done.