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    Duty Report: Annisa Ayu Rahmawati Nazza Rizky Ramdhagama

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    sasoy
    - Mr. D, a 50-year-old man, presented to the emergency department with pain and bleeding in his right toes after they were pinched between two boats while cleaning. - On examination, he had structural discontinuity and complete fractures of the distal phalanges of toes 2, 3, and 4 on his right foot. - He was diagnosed with fingertip injuries of toes 2, 3, and 4 on his right foot (Allen type IV) and treated surgically for wound closure and with antibiotics, analgesics, and tetanus immunoglobulin injections.

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    Duty Report: Annisa Ayu Rahmawati Nazza Rizky Ramdhagama

    Uploaded by

    sasoy
    38 views12 pages
    - Mr. D, a 50-year-old man, presented to the emergency department with pain and bleeding in his right toes after they were pinched between two boats while cleaning. - On examination, he had structural discontinuity and complete fractures of the distal phalanges of toes 2, 3, and 4 on his right foot. - He was diagnosed with fingertip injuries of toes 2, 3, and 4 on his right foot (Allen type IV) and treated surgically for wound closure and with antibiotics, analgesics, and tetanus immunoglobulin injections.

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    - Mr. D, a 50-year-old man, presented to the emergency department with pain and bleeding in his right toes after they were pinched between two boats while cleaning. - On examination, he had structural discontinuity and complete fractures of the distal phalanges of toes 2, 3, and 4 on his right foot. - He was diagnosed with fingertip injuries of toes 2, 3, and 4 on his right foot (Allen type IV) and treated surgically for wound closure and with antibiotics, analgesics, and tetanus immunoglobulin injections.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    38 views12 pages

    Duty Report: Annisa Ayu Rahmawati Nazza Rizky Ramdhagama

    Uploaded by

    sasoy
    - Mr. D, a 50-year-old man, presented to the emergency department with pain and bleeding in his right toes after they were pinched between two boats while cleaning. - On examination, he had structural discontinuity and complete fractures of the distal phalanges of toes 2, 3, and 4 on his right foot. - He was diagnosed with fingertip injuries of toes 2, 3, and 4 on his right foot (Allen type IV) and treated surgically for wound closure and with antibiotics, analgesics, and tetanus immunoglobulin injections.

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    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

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