Duty Report

Annisa Ayu Rahmawati

Nazza Rizky Ramdhagama
Martha Simona
Nurjannah
 Dokter Jaga Pasien
Trauma = 1 pasien
Non-Trauma = 0 pasien
Rawat inap = 1 pasien

Nama Usia Diagnosis

Mr. J 60 years old Closed Fracture Proximal Phalanges
Digiti 4,5 Manus Dextra
1st case
Identity & History

Name M Past Medical History:

Sex Male Diabetes Melitus (+)
Age 60 y/o

Family History:
(-)
Chief complaint:
Other complaints:
Pain on his right hand
Swelling on the right hand
 20:15 pm
16:45 pm IGD
(before RSUD
admitted) IGD Koja

Patient complaints
Patient was crossing pain at his right
over the street when the hand
motorcycle hit him on
the right hand
History of Present Illness

Patient claimed that he got injured when he crossing over the

street. He was hit by the motorcycle.
Loss of conciousness post trauma (-), nausea and vomitus (-)
Past medical history: hypertension (-), dm (+), asthma (-),
congenital/acquired heart disease (-), past allergy history (-).
 Primary Survey

Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), cold extremities, BP: 120/90, HR: 112 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 : 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 hand
• Look: swelling, vulnus abrasion at
dorsalis manus dextra regio with
irregular shape, regular edge, base
of wound soft tissue layer
• Feel: pain on palpitation (+),
pulsation (+)
• Move: wrist extention, wrist
flexion, abduction and opotition
limited due to pain.
Diagnosis and problem

Working diagnosis:
Closed Fracture Proximal Problems:
Phalanges Digiti 4,5 Manus • Pain
Dextra • Inflammation
• Infection
Management

SURGERY NON SURGERY

Consult orthopedy Pharmacology

Ceftriaxone 2x1g
Ketorolac 3x30mg

Non-pharmacology
Bed rest
Wound care