K/M/14yo

78.30.12
Chief complaint : lacerated wound o/t Left Foot
It has been suffered since 2 hour before
admitted to Adam Malik Hospital. He slipped
while he was playing on the street and his foot
hit the iron fence. History of nausea (-), vomiting
(-) and seizure (-), immunization was incomplete.
 Primary Survey:
A : Clear
B : Spontaneous, RR : 20 x/min
C : BP : 110/80 mmHg HR : 90 x /min
D : GCS 15
E : Lacerated wound o/t Left Foot
 AMPLE History
• A : No history of allergy
• M : No history of medication, immunization
was unclear
• P : No history of past illness
• L : 2 hour before accident
• E : Road
• VAS : 2
Localized state :
(L)Foot:
•Look :
– Lacerated wound o/t left foot
region, size 4x1x0.5 cm,
Swelling (-), Deformity (-),
irregular edge, contaminated,
subcutaneous based, active
bleeding (-).
•Feel :
– Tenderness (+)
– Crepitation (-)
•Move :
– AROM of (L) Foot (+) normal
limit, pain (-)
Working Diagnosis :
Lacerated Wound o/t Left foot
Treatment
•Injection of ATS 3000 IU IM
•Injection of TT 0,5 cc IM
•Antibiotic oral  Amoxicillin 500 mg
•Analgetic oral  Paracetamol 500mg
Plan :
• Wound Toilet
• Primary Suture
 Primary suture
• Patient in supine position
• Infiltration of local anesthesia lidocaine 2% around the wound.
• Wound was washed with normal saline and chlorhexidine until clean.
• Aseptic and antiseptic procedure was performed.
• Identification of the wound, there was a lacerated wound o/t Left foot
region, size 4x1x0.5 cm, irregular edge, contaminated, subcutaneous
based
• Wound was washed with normal saline untill debris were removed.
• Wound edge was refreshed. Bleeding was controlled.
• Wound was sutured with monofilament non-absorbable 4/0 cutting
bodied by simple interrupted sutures.
• Primary suture was done.