Duty Report

Wednesday, 13th

Balqis
Melisa
 Dokter Jaga Patient
Trauma = 1 patient
dr. Novi Non-Trauma = patient
Admitted = 0 patient

Name Age Diagnosis

Mr. S 50 yo Selulitis Pedis Dextra
1st case
Identity & History

Name Mr. S Past Medical History:

Sex Male Hipertensi
Age 50 y/o

Family History:
(-)

Chief complaint: Other complaints:

Pain at the pedis sinistra - fever
 HISTORY OF PRESENT ILLNESS

The patient came to the emergency room due to the

pain in the right ankle about 40 minute before admitted
to the hospital. Pain caused by cat scratches and
wounded since 4 days ago.He washed his wound using
NaCl then covered it with gauzed. For three days the
wound got worse. The patient also stated that he got
fever 2 days after it was clawed.
 Biomechanism of Trauma

05.00 pm
40 mins
ER
before
Koja GH
admitted
IGD

Patient was brought to

RSUD Koja
Patient complaint
The patient came to the emergency room due to the
pain at the wound
pain in the right ankle about 40 minute before admitted site
to the hospital. Pain caused by cat scratches and
wounded since 4 days ago.He washed his wound using
NaCl then covered it with gauzed. For three days the
wound got worse. The patient also stated that he got
fever 2 days after it was clawed
 Primary Survey

Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), warm extremities, BP: 180/120 HR: 82 x/mins, Temp: 37.1 C, CRT <2 sec
Disability :
GCS (E4M6V5) = 15
Secondary Survey

●Head : Bleeding (-), swelling (-), tenderness (-), hematoma (-)

●Eyes : Eyebrow (-), Isokor 3mm/3mm, CA (-/-), SI (-/-)
●Nose : Bleeding (-)
●Ear : Normotia, bleeding (-)
●Mouth : Mucosa redness, cyanosis (-),
●Neck : Enlargement of Lymph Nodes (-)
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 pedis
• Look:
Ulkus on pedis dextra
active bleeding (+)
wound : necrotic tissue
(+)
eritem (+), edema (+) and
pus (+) on pedis regio
• Feel: Tenderness (+)
Calor (+)
• Move:
ROM normal
fleksi, estensi, inversi,
eversi (+)
Diagnosis and problem

Problems:
Working diagnosis: Pain
Selulitis Pedis Dextra bleeding
Management

NON SURGERY
SURGERY
Pharmacology
Consult an
-Surgeon - Ketorolac 2 x 30 mg IV
-Interna - Omeprazole 1 x 40 mg
- Cut the necrotic tissue
- Bandage with pressure