Duty Report

Sidqi
Fitri
Sharifah Khalidah Syed Khalid
Nur Aisyah Amirah
 Doctor on call Patient
dr. Adam Trauma = 2 patient
dr. Rizky Non-Trauma = 0 patient
Admitted = 2 patient

Name Age Diagnosis

Mr. S 41 yo Open fracture distal phalanx of right big toe
Mr. Y 32 yo Open fracture of distal radius ulna left forearm
Dislocation of left elbow joint
1st case
Identity & History

Name Mr. S Past Medical History:

Sex Male (-)
Age 41 y/o

Family History:
(-)

Chief complaint: Other complaints:

Pain at the big toe of right foot Bleeding
History of Present Illness

10:00 am IGD
09:30 am
RSUD
IGD Koja

Patient was brought to

Puskesmas Papanggo
Patient was crushed by Patient complaints
and transferred to RSUD
iron bench while pain and bleeding
Koja
moving it at wound site

Biomechanism of Trauma
 Primary Survey

Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), warm extremities, BP: 120/80, HR: 81 x/mins, Temp: 36.0 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 right big toe

• Look: nail broken, bleeding (+),

swelling (+), deformity (+),
laceration wound 0.3cm x 0.1cm x
0.1cm. Base of wound connective
tissue, irregular edge, clean wound
• Feel: pain on palpation, crepitation
(+)
• Move: ROM normal
Diagnosis and problem

Working diagnosis: Problems:

• Pain
Open fracture distal phalanx of • Bleeding
right big toe • Infection
• Wound
Management

SURGERY NON SURGERY

Consult an orthopaedic Pharmacology

Ketorolac 3x30mg
Tetagam

Non-pharmacology
Bed rest
Wound care (nail removal)
Hecting
2nd case
Identity & History

Name Mr. Y Past Medical History:

Sex Male (-)
Age 32 y/o

Family History:
(-)
Chief complaint:
Other complaints:
Bleeding and unable to move
Pain and stiffness
left hand
History of Present Illness

09:15am ER
09:00am
RSUD
IGD Koja

Patient was brought to

Puskesmas and
Patient was repairing Patient complaints
tranfered to RSUD Koja
roof of his house and of non stop
suddenly fell off from 5 bleeding and
metres on the left hand unable to move left
touch the ground first. hand.

Biomechanism of Trauma
 Primary Survey
Airway :
Airway obstruction (clear)

Breathing :
Spontaneous breathing (+), retraction (-), RR: 18 x/mins

Circulation :
Pulse (+, regular), cold extremities on left hand only, BP: 80/60, HR: 101 x/mins, Temp: 37.2 C, CRT
>2 sec on left hand, SaO2: after 3hours assessment  70% on left hand, 99% on right hand

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 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 anterior elbow region
• Look: Laceration wound 5cm x
3.5cm x 2cm, base of wound bone
and fat tissues, regular edge,
contaminated wound, bleeding (+),
swelling (+), deformity (+)
• Feel: crepitation (-) tenderness (+)
brachial artery weaker than the right
elbow
• Move: limitation of flexion,
extension, pronation, supination of
the elbow
 Local state of left forearm region
• Look: Laceration wound 3cm x
1.5cm x 0.5cm at distal of left
forearm, base of wound fat tissues,
irregular edge, contaminated
wound, bleeding (+), swelling (+),
deformity (+)
• Feel: crepitation (+) tenderness (+)
radial artery and ulnar artery
weaker than the right forearm
• Move: limitation of wrist flexion,
finger flexion
Diagnosis and problem

Working diagnosis: Problems:

• Open fracture
Open fracture of distal radius • Dislocation
• Laceration wound
ulna left forearm, Dislocation of • Swelling
left elbow joint • Infection
• Vascular injury
Management

NON SURGERY
SURGERY
Pharmacology
Consult an orthopaedic Ceftriaxone 2x1g
Ketorolac 2x30mg
Nacl 0,9% IV

Non-pharmacology
Bed rest
Wound closure
Immobilization