DUTY REPORT

SUNDAY, OCTOBER 27th 2019

Submitted for completing task in Surgery Department Faculty of Medicine

Diponegoro University

Coass on Duty :
Nabila Adzhana 22010118220155
Galih Bhakti Sadewo 22010118220163

Supervisor :
dr. Kamal Adib, M.Kes., Sp.OT

SURGERY DEPARTMENT
FACULTY OF MEDICINE DIPONEGORO UNIVERSITY
BATANG PUBLIC HOSPITAL
2019
 DUTY REPORT, SUNDAY, OCTOBER 27th 2019

Coass on duty : Nabila Adzhana 22010118220155

Galih Bhakti Sadewo 22010118220163

In Emergency Installation we received 1 patient, consist of :

NO. Patient Identity Diagnosis Initial Plan

1. Mr. Dasmui/ 55 Laceration wound of the -Wound toilet

distal femur sinistra caused
years old -Wound Suturing
by fell of from 3 meters
heights 2 hours before -Mefenamic acid 3x500 mg
admission
PO
-Amoxicillin 500 mg per 8
hours PO
-ATS 1500 IU IM
-X-photo genu sinistra AP
Lateral
Discharged
 CASE REPORT

Identity :
Name : Mr. Dasmui
Medical Record : 421443
Date of Birth : 12 March 2002
Address : Kalipucang, Batang

PRIMARY SURVEY
Airway and c-spine control : clear when talking  clear airway
Breathing and ventilation : RR : 20 x/min, regular, symmetrical when static and
Dynamic
Circulation and bleeding control : HR : 98 x/min, regular, BP : 130/65 mmHg
Disability : GCS E4M6V5 = 15, light reflex (+/+)
Exposure : Vulnus laceratum (+) on distal side of left femur

ANAMNESIS
Chief Complaint: Open wound on the inner of left thigh
History of Present Illness:
A 55-year-old man came to the emergency room after he was slipped and fell off from the 3
meter roof 2 hours being hospitalized. He was fell off from the roof with the condition his left
thigh got hit by an iron when he landed on the ground . The patient was still conscious before
and after the accident and can still remember the incident. After the accident an open wound
with active bleeding on the inner side of the patient’s left thigh can be seen. Then the patient was
immediately taken to the Puskesmas Kandeman and he got situational suturing and referred to
the Batang Public Hospital. The patient did not remember when was the last time he received
Tetanus vaccination.
History of Past Illness:
 History of high blood pressure (-)
 History of Asthma (-)
 History of allergy (-)
Family Illness History:
 History of high blood pressure in family was denied
 History of asthma in family was denied
Socio-economy History:
Patient is a labor. He lives with his wifer and his daughter. The administration and payment
with BPJS PBI..

PHYSICAL EXAMINATION:
General appearance : looks in moderate pain
Consciousness : GCS 15 (E4M6V5)
Vital signs : Blood pressure : 130/65 mmHg
Respiratory rate : 20x/min, regular, shortness of breath (-)
Pulse : 98x/min, regular, strong and normal pulse force
Body temperature : 36,5°C
Pain : 5 VAS
Head : mesocephal
Eyes : isocorous pupil, light reflex (+/+), racoon eyes (-/-) proptosis (-),
icteric sclera (-/-), pale palpebral conjunctiva (- / -),
Nose : nostril breathing (-), discharge (-/-)
Mouth : pinkish mucous, lesions (-), dry lips (-), cyanosis (-)
Ear : normotia, discharge (- / -)
Neck : lesions (-), symmetric, tracheal deviation (-), neck stiffness (-)
Thorax : symmetrical, retraction (-)
Respiratory
Inspection : chest wall movements are symmetrical statically and dynamically
Palpation : the right hemi thorax fremitus stem is the same as the left side
Percussion : sonor both left and right lung fields
Auscultation : vesicular base sound (+ / +), additional sound (- / -)
Cardiovascular
Inspection : ictus cordis visible (-)
Palpation : ictus cordis palpable in SIC V left midclavicular line, strong lift (-),
thrill (-)
Percussion : heart border within normal range
Auscultation : pure I-II heart sounds, noisy (-), gallop (-)
Abdomen
Inspection : flat (+), venectation (-), bruise (-)
Palpation : muscle rigidity (-), mass (-)
Percussion : tympanic, liver dullness (+), shifting dullness (-)
Auscultation : bowel sound (+) N

Extremities
Superior Inferior
Cyanosis -/- -/-
Cold temperature -/- -/-
Edema -/- -/-
Capillary refill time <2”/<2” <2”/<2”

Local Status:
Left ankle region
Inspection : skin discontinuation (+); subcoutan based, regularly shaped, regular border,
active bleeding (+)
Palpation : pressure pain (+), 14 x 2 x 1 cm in size, a.femoralis pulsation(+), a.popliteal
pulsation(+), a.dorsalis pedis pulsation(+)

WORKING DIAGNOSIS
Vulnus laceratum of the distal side of left femur region caused by fell off from 3 meters
heights 2 hours before admission
CLINICAL PHOTOS

INITIAL PLAN:
IP Dx :
S:-
O : X-Photo Genu AP-Lateral
IP Tx :
• Wound toilet with NaCl 0.9%
 • Wound suturing
• Mefenamat acid tab 3x500mg prn
• Amoxicillin tab 250mg/12 hours PO
• ATS 1500 IU injected intramuscularly
 Discharged
IP Mx :
Pain monitoring, wound suture
IP Ex :
- Explain to patient and the family about the diagnostic
- Explain to patient and the family about the necessity of wound toilet and suturing
to clean the site and avoid infection
- Explain to patient and the family that the patient may be discharged and will be
prescribed with antibiotic and pain killer for his pain. The drugs prescribed to be
taken accordingly as doctor instruction
- Explain the necessity to keep the suture wound clean and dry