DUTY REPORT

11/10/19
By :
- Ranny
- Rizauddin
- Tiara
- Humaerah
Doctor on duty Patients
dr. Putri Trauma = 3 patient
Non-Trauma = 0 patient

Name Age Diagnosis

An. A 4 y/o Tuft fracture of 4th finger manus
dextra
Mr. A 29 y/o Closed fracture of 1/3 os tibia
and fibula sinistra
Mrs. N 48 y/o Dislocation of left elbow
CASE 1
1. An. A/ 4 YRS

• Chief complain:
pain on her 4th finger of right hand one hour before entering hospital
• Additional complains:
Active bleeding on 4th finger of right hand
 History of present illness

The patient came to ER of Koja’s Hospital with chief

complaint of great pain on her 4th finger after the finger
was squeezed in between foldable desk one hour
before coming to the ER. She complained that there is
bleeding at the site of injury and had restriction to
move her finger.
 Mechanisme of Trauma

An hour before
coming into ER, the
patient’s finger was
squeezed between
a foldable desk Right after that he
while trying to fold was brought to Koja
the desk. Hospital

The squeezing
cause the finger to
bleed.
 PRIMARY SURVEY

Airway: CLEAR

Breathing: SPONTANEOUS

Circulation: STABLE

Disability: GCS  E4M6V5

Exposure: no visible injury

 SECONDARY SURVEY

HEAD : normocephal, wound (-), edema (-), crepitation (-),

tenderness (-)

EYES : pupil reactive 3mm/3mm isokor, CA(-/-), SI(-/-)

NOSE : rhinorea (-)

EARS : otorea (-)

MOUTH : pink, cyanosis(-)

NECK : lymph nodes not palpaple -

Thorax
Inspection : symmetric chest
expantion, effortless
respiration, retraction (-)
Palpation: tenderness (-),
weakened vocal fremitus,
masses(-)
Percusion: tympanitic
Auscultation: VS ICS 5-6
sinistra, Rh(-/-), Wh(-/-). HS
I&II regular.
Abdomen
• Inspection: flat, masses
(-)
• Auscultation: bowel
sound present
• Palpation: tenderness(-),
defans muscular(-)
• Percussion: tympanitic
• Extremities: CRT <2,
edema (-), crepitus (-),
bleeding (+)
 Localist State

Look : vulnus laceratum on distal

of 4th digiti manus dextra with the
size of 1 cm x 0,4 cm.

Feel: tenderness +

Move: movement limited due to

pain
Radiology
 Diagnosis

• WD
Tuft fracture of 4th finger dextra

• DD:
• finger tip injury
 Problems
• Pain on 4th finger
• Bleeding
 Treatment
Surgery: Non-surgery
consult an orthopaedic  Pharmacology

 TIG (250IU,IM)

 Non-pharmacology

 Wound cleaned with NaCl

0,9%, povidone iodine

Wound suture
CASE 2
1. Mr. A/ 29 YRS
• Chief complain:
left leg cannot be moved 1 hours prior admitted to the hospital
• Additional complains:
Pain on the left leg
 History of present illness

The patient came into Koja’s Hospital Emergency room

with chief complain of left leg cannot be moved an hour
before. The patient was hurt by a stranger. The patient
also complained pain in his left leg. Unconciousness(-),
nausea(-), vomit(-), headache(-), blurred vission(-).
Mechanisme of Trauma
 PRIMARY SURVEY

Airway: CLEAR

Breathing: SPONTANEOUS

Circulation: STABLE (BP: 110/80mmHg, HR:

84x/menit)

Disability: GCS  E4M6V5

 SECONDARY SURVEY

HEAD : normocephal, wound (-), edema (-),

crepitation (-), tenderness (-)
EYES : Pupil reactive 3mm/3mm isokor, CA(-/-), SI(-/-)
NOSE : rhinorea (-)
EARS : otorea (-)
MOUTH : pink, cyanosis(-)
NECK : lymph nodes not palpaple -
Thorax
Inspection : symmetric chest
expantion, effortless
respiration, retraction (-)
Palpation: tenderness (-),
weakened vocal fremitus,
masses(-)
Percusion: tympanitic
Auscultation: VS ICS 5-6
sinistra, Rh(-/-), Wh(-/-). HS crepitus (+) deformities (+),
I&II regular.
Abdomen
• Inspection: flat, masses (-)
• Auscultation: bowel sound
present
• Palpation: tenderness(-),
defans muskular(-)
• Percussion: tympanitic
• Extremities:
Left leg: CRT <2, edema (+),
can’t move freely
 Localist State

Look : edema (+)

deformities (+)

Feel : tenderness to
light palpation (+),
crepitation (+)

Move: ROM was

limited
1.Adequate photo
(Identity, marker)
2. There’s a
malalignment
• Fracture complit,
spiral, 1/3 medial
os tibia sinistra
• Fracture
comminutive 1/3
medial os fibula
sinistra
4. Soft tissue
swelling (+)
 Diagnosis

WD:
• Closed fracture of 1/3 medial os tibia and fibula
sinistra

DD
• Dislocation
 Problems
• Pain on his left leg
• Edema
• Limited ROM
 Treatment
Surgery: consult an orthopaedic

Pharmacology

- Ceftriaxone 1g inj

- Ketorolac inj 30mg.

Non pharmacology

• Imobilization
CASE 3
1. Mrs. N/ 48 YRS
• Chief complain:
Pain on left arm an hour before admitted
• Additional complains:
Unable to move her forearm
Wound on facial regio
Pain on facial regio
 History of present illness

Patient came to ER Koja Hospital with chief complient of

great pain on her left arm since an hour before
admitted. An hour before, she was fell into a ditch while
trying to jump. She fell on a prone position and her
hand was on an extension. Then she hit the wall of the
ditch with her face. Right after that, she couldn’t move
and straighten her left arm. There are wounds on her
nose and piltrum.
For other complaints: headache (-), nausea and
vomitting (-), blurry vision (-), active bleeding (-)
Mechanisme of Trauma
 PRIMARY SURVEY

Airway: Airway obstruction clear, Patient can

speak
Breathing: Symmetrical chest, chest
movements (+), retraction (-), RR:
20x/minutes
Circulation: Pulse (+) reguler, warm
extremities, cyanosis (-), HR: 72x/minutes, BP:
120/80mmHg, CRT <2 sec
Disability: GCS  E4M6V5
 SECONDARY SURVEY

HEAD : normocephal, wound (+), edema (-),

crepitation (-), tenderness (+)
EYES : Pupil reactive 3mm/3mm isokor, CA(-/-), SI(-/-)
NOSE : rhinorea (-), bleeding (-), Swelling (+)
EARS : othorea (-)
MOUTH : pink, cyanosis(-)
NECK : lymph nodes not palpable (-)
Thorax
Inspection : symmetric chest
expantion, effortless
respiration, retraction (-)
Palpation: tenderness (-),
weakened vocal fremitus,
masses(-)
Percusion: tympanitic
Auscultation: VS ICS 5-6
sinistra, Rh(-/-), Wh(-/-). HS Lower extremities: warm,
I&II regular.
Abdomen
• Inspection: flat, masses
(-)
• Auscultation: bowel sound
present
• Palpation: tenderness(-),
defans muskular(-)
• Percussion: tympanitic
• Extremities:
CRT <2sec
 Localist State
Look : deformity (+),
swelling (-)

Feel : tenderness to
light palpation (+),
crepitation (-), pulse of
a. Radialis (+)

Move: ROM was

limited
Elbow flexion: 75°
Elbow extension: 10°
Wrist flexion and
extension: normal
Thumbs up (+)
Fingers abduction (+)
O sign (+)
 Localist State

Vulnus excoriatum
on nasal regio, size
1cm x 2 cm, base of
wound: soft tissue,
no active bleeding
Swelling (+),
tenderness (+),
crepitation (-)

Vulnus excoriatum
on piltrum regio,
size 2cm x 2cm,
base of wound: soft
tissue, no active
bleeding
Radiology
 Diagnosis

WD:
Dislocation of left elbow

DD:
Ligament injury
 Problems
• Pain on left arm
• Deformity
• Limited ROM
• Wound on facial regio
 Treatment
Surgery: consult an orthopaedic

Non surgery: wound toilet

Pharmacology :

- Ketorolac inj 30mg.

Non pharmacology:

• Imobilization