Emergency Case Report

Emergency doctor : dr. Linda

Alex Chandra
2009-061-169

Patient Identity
Name
: Santi
Age
: 28 years old
Date of Admision
: 13th august
2011 at
10.30 am
Chief Complaint:
Pain at feet toe

Primary Survey
UNIVERSAL PRECAUTIONS :
Hand gloves

AIRWAY :
Clear
Patient spoke fluently, good articulation
Cervical spine control with collar neck: no
need
No tracheal deviation, no neck vein distention,
palpable carotid pulse, neck mobilization to every
direction +.

 Listen and feel the movement of air :

Assessment :
Snoring
Gurgling
Stridor

Re-evaluation :
The movement was synchronized with chest
movement

BREATHING :
RR : 16 x/min, spontaneous, regular
O2 not needed

CIRCULATION :

Blood pressure 110/70 mmHg, CRT < 2

detik, cyanosis -

DISABILITY :

GCS 15 (E4M6V5)

EXPOSURE:

Axillar temperature: 36.30C

Secondary Survey
History Taking

History of Present Illness

Chief complaint
pain at feet toe

Additional complaint
Pain when walking at feet toe

History Taking
About 2 hours before admitted to the ER,
patient kick standart of motorcycle because
the standart was hard to open. So patient
feel pain at nails at feet toe. The toe still can
to move although there is a pain when move
it. Then the patient come to ER.
No history of previous illnesses

 Theres an avulsi nail at toe no active

bleeding, pain+, the base was purplish

DIAGNOSIS
Avulsi nail at digiti pedis I dextra with
the base was purplish

Therapy
Extraction nail

THANK
YOU