Duty Report

October 23rd 2018

Case Report (jam 21.00 October 23 2018)
A 42 years old woman, delivered to Emergency department of Batang regional general
hospital because of the injury of her toe.

Chief complain: pain in the right toe

History of illnes :
± 3 hours before entering the hospital, the patient's right foot was hit by a big stone.
initially the patient walked in front of the house, the patient's right leg accidentally
nudged a big stone on the foundation so that the stone fell and directly hit his right
foot, especially the toes. Then the right 3rd toe was injured. Blood (+), bone bulging
(+), pain (+), patient couldn’t move the toe.
Then the patient was brought to the general practitioner around her house and the
doctor was adviced the patient to went to Emergency department of Batang
regional general hospital
History of past illness:
History of hypertension (-)
History of diabetes mellitus (-)

History of Allergy : (-)

History of Medication: (-)

Physical Examinations :
General condition :
GCS : E4M6V5
Vital sign : RR : 20 times/min (regular, adequate depth of breath)
PR : 92 beats/min (regular, adequate tone and volume)
BP : 140/ 90 mmHg (MAP : 107)
Sat O2 : 99% (room air)
t : 36oC
pain scale :6
Head : normocephalic
Eye : pale conjunctiva palpebra (-/-), shrunken eyes (-/-)
isocoric round pupil 3mm in diametres, light reflex (+)
Ear : discharge (-)
Nose : discharge (-)
Lips : pale (-), sianosis (-), dry (-)
Neck : JVP not increase, trachea on mid line.
Skin turgor: fast
Chest : injury mark (-)
Heart: I : ictus cordis was not seen, injury mark (-)
Pa : ictus cordis palpated on 5th intercostal space, 2 cm
from medial mid clavicle line
P : Configuration within normal limits
A : Pure heart sound, no additional sound

Lung : I : Static : right hemithorax = left hemithorax

Dynamic : right hemithorax = left hemithorax
Pa : stem fremitus right hemithorax= left hemithorax
P : Sonor all around area
A : Vesiculer (+/+), additional sound (-)
Abd : I : Flat , bowel loops (-), bowel movement (-)
Pa : Distended (-), tenderness (-) defance (-), palpable mass
(-)
Pe : Tympanic,
A : Bowel sound (+) Normal

Extremities : Upper Lower

cyanosis -/- -/-
cold acral -/- -/-
deformities -/- +/-
edema -/- -/-
motoric 55555/55555 55555/55555
sensoric +/+ +/+
Status Localis: regio pedis dextra

Inspection: deformity in digiti III pedis dextra. in dorsum digiti III there is
open wound, bone expose (+), irreguler edge of the wound
Palpation: tenderness (+), crepitation (+) warm acral (+), palpable a.dorsalis
pedis and tibialis posterior
Move: limited
Working Diagnosis (October 23 2018)
• Open fracture digiti III pedis dextra grade IIIb
Initial Management
IpDx :
S: -
O : X ray pedis dextra AP dan lat

IpTx :

• IVFD RL 20 tpm
• ATS 1500 U
• Ceftriaxon inj 2x1 gr IV
• Ketorolac inj 2x1 amp IV
• Consult to orthopedic spesialist

IpMx : General condition, vital signs, pain scale, movement

IpEx : Inform consent : diagnosis, examination plan, prognosis
Radiologic Study (23/10/2018)
X – Ray pedis dextra AP and lateral
• Discontinuity in middle phalanx digiti III
• Aposition and alignment are not good
• bone stucture is good
Conclusion: Open fracture in middle
phalanx digiti III pedis dextra