Duty Report

25 Oct
Annisa Ayu Rahmawati
Nazza Rizky Ramdhagama
 Dokter Jaga Pasien
Trauma = 1 pasien
Non-Trauma = 0 pasien
Rawat inap = 1 pasien

Nama Usia Diagnosis

Mr. D 50 years old Fingertip injury of right toes 2,3,4
Allen type IV
1st case
Identity & History

Past Medical History:

Name M Diabetes Melitus (-)
Sex Male Hypertension (-)
Age 50 y/o Alergy (-)

Family History:
(-)
Chief complaint:
Other complaints:
Pain on his right toes
Bleeding on his right toes
 20:15 pm
16:05 pm IGD
(before RSUD
admitted) IGD Koja
16:30

Patient complaints
Patient was cleaning the pain and bleeding
boat while suddenly his at his right toes
toes pinched between 2
boats
 Primary Survey

Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), cold extremities, BP: 120/70, HR: 112 x/mins, Temp: 36.4 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 LN (-)
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
right toes

• Look: sutured wound, irregular

edge, based of wound : bone,
active bleeding (+)
• Feel: pulsation (+)
• Move: limited range of
movements due to pain
Mr. Darma, male, 50 years old,
photo of pedis dextra AP Lateral

There are structural discontinuity

on distal phalang digiti 2,3,4,
complete
Diagnosis and problem

Working diagnosis: Problems:

Fingertip injury of right toes 2,3,4 • Pain
Allen type IV • Inflammation
• Infection
• Bleeding
Management

SURGERY NON SURGERY

Wound closure Pharmacology

Consult orthopedy Ceftriaxone 2x1g
Ketorolac 3x30mg
TIG 250IU IM

Non-pharmacology
Bed rest
Wound care