Ershanty rahayu S.

Yasin
K1A110046

Supervisor :
Dr. Moh Rizal Alisi, M.Kes, Sp.OT
 IDENTITY

Name : Mr. a
Age : 43 years old
Address : Laeya Village, south konawe
Occupation : construction worker
Admission : august, 2nd 2018 at 09.50 WITA
Doctor in Charge : dr. Muh. Rizal Alisi, M. Kes, Sp.OT
 HISTORY TAKING
(09.40)
• Chief complain : Wound at right foot
• Anamnesis (Alloanamnesis) :
• Since 3 hours ago before admitted to the hospital due to traffic accident
• Mecanism of trauma : Patient was riding a motorcycle with moderate speed and not using helmet
then suddenly got hit by a motorcyle. Mechanism of trauma was unknown
• History of trauma :
 history of unconsciousness (+), nausea (-) and vomiting (-)
 There was no history of drugs or drink alcohol.
 There was a history of previous medication, divided in medicamentosa treatment with IVFD RL
and ketorolac injection from the previous hospital.
PRIMARY SURVEY
A
clear

B
RR = 28x/min, symmetric, spontaneous

C
BP = 150/100 mmHg, HR = 90x/min, reguler, strong

D
GCS 15 (E4V5M6), light reflex +/+ , pupil isochors, Ø : 2.5 mm/2.5mm

E
T = 36,60C (axillary)
SECONDARY SURVEY (22.15)

General State
The patient was conscious with moderate ill, good nutritional status
SECONDARY SURVEY

Vital Sign
BP = 120/80 mmHg
HR = 72x/m, regular, strong
RR = 20x/m, regular, symetris
Temperature = 36,6oC/axillary
VAS = 8/10
SECONDARY SURVEY

Status Present

Head : Localized state Neck : Within normal limit

Face : Within normal limit Chest : Within normal limit
Eyes : Within normal limit Abdomen : Within normal limit
Nose : Within normal limit Upper extremity : Localized state
Mouth : Within normal limit Lower extremity : localized state
Ears : Within normal limit
LOCALIZE STATE
• Manus dextra Region

I : Deformity (-), swelling (-), hematoma (-), wound (+) vulnus excoriatum size 0,4 x 0,1 cm
P : Tenderness (+)
ROM : Active and passive motion at wrist joint is within normal limit

NVD: Sensibility ulna nerve is good, radialis nerve is good, medianus is good. Pulse of Ulnaris artery is
palpable, radialis artery is palpable. CRT < 2 seconds
Clinical Finding
LOCALIZE STATE
• pedis dextra Region

I : Deformity (+), swelling (+), hematoma (+), wound (+) at digiti 4 and 5
P : Tenderness (+)
Clinical Finding
Planning Diagnostic :

X-Ray pedis dextra AP

Routine Blood
Pedis dextra AP
Routine Blood

PARAMETER Nilai Nilai rujukan

WBC 15,75 4,00 - 10,00

RBC 4,87 4,00 - 6,00

HGB 13,7 12,0 - 16,0

HCT 41,6 37,0 - 48,0

PLT 212 150 – 400

Coagulation factor Blood

PARAMETER Nilai Nilai rujukan

Bleeding time 2’30” ≤ 3 menit

Clothing time 10’00” 6-12 menit

DIAGNOSIS

Open fracture vulnus

amputatum digiti V pedis
dextra
DD/ : soft tissue injury pedis dextra
dislokasi
 MANAGEMENT
Non-Pharmacology
• Rest
• Immobilisation
• Compress Ice
• Elevation
• Education
Pharmacology
• IVFD
• Antibiotic inj
• Analgesic Inj
• H2 Receptor Agonis Inj
Consult Orhtopedic Surgeon
L/O/G/O

Thank You

BAGIAN ILMU
BEDAH