A/M/93yo

00.54.23.27
Chief Complaint : Can not to miction
The patient came to the emergency room at the
Pirngadi Medan General Hospital with complaints
of a wound on the sole of his left foot due to
being hit by a hoe while cleaning a paret. The
patient experienced this 30 minutes before
entering the hospital emergency room, the
patient also complained of pain around the
wound and weakness.
 AMPLE
• Allergic : no history of allergic
• Medication : no history of medication
• Past illness:The patient said there was no
history of previous illness
• history of drug use: the patient said there was
no drug use
 Present state
Awareness : composmentist consciousness
BP : 120/70 mmHg
HR : 80 bpm
RR : 20 tpm
T : 36.7oC
 Generalized State
Head and neck : no abnormality was found
Chest : no abnormality was found
Abdomen : in localized state
Genitalia : male, no abnormality was found
Extremity :
in the upper extremities: no abnormalities were
found.
on the lower extremities: there was a
torn wound on the sole of the left
foot caused by a sharp object with a
length of approximately 20 CM, a
depth of 2-3 CM and a severed
tendon was also found in the flexor
hallucis longus tendon
 Localized state
Abdomen :
• I : symmetrical, distended (-)
• A : Peristaltic was (+) normal
• P : tenderness (-) on the whole abdomen, muscular
rigidity (-)
• P : Tympani
 Laboratory Findings
Laboratory examination: not carried out
Rontgen pedis sinistra Ap /Lat
 Working Diagnosis
Vulnus Laceratum pedis sinistra

Plan

tendon splicing surgery, stitching wounds

Treatment in the Emergency room
TIME TREATMENT
20.00 IVFD crystalloid 🡪 Ringer lactate 20 dpm

20.05
• Pedis sinistra AP lateral X-Ray
• USG
20.30 Stitch the wound and stop the bleeding
action procedures
1. type of wound: determine the type of wound, whether it is a
single wound or multiple wounds. In this case, a single wound was found
2. Wound area: in this case it was found in the lower extremity region,
specifically on the sole of the left foot
3. wound contamination: before further action is taken, it is previously
determined whether the patient's wound is dirty (contaminated) or clean
(not contaminated). Patients found dirty or contaminated wounds as a
result of using paret cleaning tools, where these tools came into contact
with many microorganisms, including bacteria, viruses, fungi and so on.
4. Clean around the wound
5. give local anesthesia in the form of 2% lidocaine
6. Wound irrigation and debridement: the patient is irrigated on the wound
using 0.9% NaCL after being anesthetized using 2% lidocaine, then clean the
dirt stuck to the wound then drip H202 and the next thing is to drop
Betadine.
7. Wound suturing:
8. wound dressing