DUTY REPORT

DECEMBER 24th 2018

A. PATIENTS LIST
In emergency installation we received 2 surgical patients, which are:
No Name/Age Diagnosis Management

1. Mr. S/50 years old Closed fracture of left Splint application

antebrachii e.c traffic X ray left antebrachii AP and
accident 2 hours before lateral view
admission Ketorolac 30mg/8 jam
Excoriate wound at Wound toilet
regio manus sinistra Pro ORIF
2. Mr. T / 53 years Closed fracture of left Immobilitation
old clavicle e.c traffic X ray chest AP
accident 2 hours before Ketorolac 30mg/8 jam
admission Pro ORIF

B. CASE REPORT1
I. PATIENT IDENTITY
Name : Mr. S
Age : 50 years old
Gender : male
Occupation : construction laborer

II. PRIMARY SURVEY

▰ Airway and C spine control

Speak clearly, no snorng, no gargling, no stridor, no neck pain

Airway and C-spine control  CLEAR

▰ Breathing and ventilation

 Respiratory rate: 18x/minute, reguler, adequate inspiration, chest symmetry in static
and dynamic, no injury, no retraction
Breathing and ventilation  ADEQUATE

▰ Circulation and hemorrhage control

Pulse rate 80x/minute, regular, enough tone and volume, no cyanosis, no active
bleeding, no cold acral, capillary refill time <2”, blood pressure 110/80 mmHg
Circulation dan Hemorrhage control  STABLE

▰ Disability

GCS 15 (E4M6V5) , isocoric pupil, diameter 3mm/3mm, round, light reflex (+/+),
neurology deficit (-)

▰ Exposure

No life-threatening injury

III. SECONDARY SURVEY

ANAMNESIS
Autoanamnesis with patient in the emergency instalation on December 24th 2018 at
22.00 WIB
Chief complain : pain on the left arm
History of illness :
± 2 hours ago before admission, patient experienced traffic accident while
trying to avoid a cat on the street. Patient rode the motorcycle with his neighbor sit
behind. Both of them fell off from the motorcycle with the left side of the body
bumped to the street first. He couldn’t tell the exact position of his left arm when he
fell, but he only recall that his left arm bumped to the street and pinned under
motorcycle. After the accident patient felt pain on his left arm and couldn’t move his
arm. Patient used helmet, he denied any head bump, syncope, bleeding, dizziness,
vomiting, and nausea.
History of past illness:
History of past trauma (-)
History of hypertension (-)
History of diabetes mellitus (-)
History of allergic (-)
History of operation (-)
History of family illness:
History of hypertension (-)
History of diabetes mellitus (-)
History of allergic (-)
History of social and economic state
Patient is a contruction laborer which use BPJS PBI for paying hospital bill.
PHYSICAL EXAMINATION
◦ General condition : Moderately ill
◦ Consciousness : Composmentis, GCS 15 (E4M6V5)
◦ Vital signs
Respiratory rate : 18x/minute (regular, enoughi in depth, retraction (-))
Pulse rate : 80x/minute (regular, enough tone and volume)
Blood pressure : 110/80 mmHg
Temperature : 37,7o C (Axiller)
VAS :5
◦ General status
Eye : Conjunctiva anemic (-/-)
Nose : rhinorrhage (-/-), rhinorhea (-/-), injury (-), deformity (-)
Ear : otorrhage (-/-), otorrhea (-/-), othematome (-/-), injury (-)
Mouth : cyanotic lips (-), dry lips (-), injury (-), bleeding (-)
Neck : Injury (-), trachea deviation (-)
Chest
Lung
Inspection : symetric at static and dynamic, no injury, no retraction
Palpation : tactile fremitus was equal on both side
Percussion : sonor on all area
Auscultation : vesicular breath sound (+/+), no additional breath sound
Heart
Inspection : Ictus cordis was not seen
Palpation : palpable Ictus cordis at 5th ICS, 2 cm medial LMCS
Percussion : normal configuration
Auscultation : heart sound normal, reguler, no gallop, no murmur
Abdominal
 Inspection : flat, injury mark (-), bowel pattern/movement unseen
Auscultation : bowel soung (+) normal
Palpation : tenderness (-), liver and spleen not palpable
Percussion : tympani, liver dullness (+), shifting dullness (-)
Extremitas Superior Inferior
Cyanosis -/- -/-
Cold Acral -/- -/-
Capillary Refill Time <2”/<2” < 2”/<2”
◦ Local Status (antebrachii sinistra)
Look : redness (-), swelling (+), deformity (+), bleeding (-), vulnus
excoriatum (+) at dorsum manus sinistra
Feel : tenderness (+), crepitation (-), bone irregularity (+), axial pain (+),
radialis pulse (+), sensoric sensation (+), hipesthesi (-)
Move : flexion-extention of the finger (+), limited wrist-elbow movement
due to pain

IV. CLINICAL PRESENTATION

V. CLINICAL DIAGNOSIS
Suspect closed fracture of the left antebrachi

VI. INITIAL PLAN

• Ip Dx S:-
O : routine blood test, X photoAP and lateral of left antebrachial regio
• Ip Tx:
– wound toilet
– Splint application
– Ringer lactat infussion 20 dpm
– Ketorolac 1 amp/8 hours intravenous injection
– ATS 1ampul
– Ceftriaxon 1 gram/ 12hours intravenous injection
• Ip Mx :
Pain, wound condition
• Ip Ex :
Giving information about patient condition which his arm bone was broke and
asking consent for hospitalisation in preparation of further correction by doing
surgical procedure in order to repair bone position.
VII.RADIOLOGY

There is bone dyscontinuity of radius sinistra at 1/3 middle shaft with distal
fragment displaced to dorsal aspect, surrounded by soft tissue swelling and
radioulnar dislocation.

VIII. DIAGNOSIS
Complete closed fracture of radius sinistra 1/3 middle shaft non complicata with
radioulnar dislocation

IX. TREATMENT
Pro Open Reduction Internal Fixation
C. CASE REPORT2
I. PATIENT IDENTITY
Name : Mr. T
Age : 53 years old
Gender : male
Occupation : construction laborer

II. PRIMARY SURVEY

▰ Airway and C spine control

Speak clearly, no snorng, no gargling, no stridor, no neck pain

Airway and C-spine control  CLEAR

▰ Breathing and ventilation

Respiratory rate: 20x/minute, reguler, adequate inspiration, chest symmetry in

static and dynamic, no injury, no retraction
Breathing and ventilation  ADEQUATE

▰ Circulation and hemorrhage control

Pulse rate 88x/minute, regular, enough tone and volume, no cyanosis, no active
bleeding, no cold acral, capillary refill time <2”, blood pressure 130/80 mmHg
Circulation dan Hemorrhage control  STABLE

▰ Disability

GCS 15 (E4M6V5) , isocoric pupil, diameter 3mm/3mm, round, light reflex

(+/+), neurology deficit (-)

▰ Exposure

No life-threatening injury

III. SECONDARY SURVEY

ANAMNESIS
Autoanamnesis with patient in the emergency instalation on December 24th 2018 at
22.00 WIB
Chief complain : pain on the left shoulder
History of illness :
± 2 hours ago before admission, patient experienced traffic accident while
trying to avoid a cat on the street. Patient got a ride whose position sit behind his
neighbor who riding motorcycle. Both of them fell off from the motorcycle with the
left side of the body bumped to the street first. He fell with his left shoulder and
chest bumped to the street. After the accident patient felt pain on his left shoulder
and couldn’t move his arm. Patient used helmet, he denied any head bump, syncope,
bleeding, dizziness, vomiting, and nausea.
History of past illness:
History of past trauma (-)
History of hypertension (-)
History of diabetes mellitus (-)
History of allergic (-)
History of operation (-)
History of family illness:
History of hypertension (-)
History of diabetes mellitus (-)
History of allergic (-)
History of social and economic state
Patient is a contruction laborer which use BPJS PBI for paying hospital bill.
PHYSICAL EXAMINATION
◦ General condition : Moderately ill
◦ Consciousness : Composmentis, GCS 15 (E4M6V5)
◦ Vital signs
Respiratory rate : 20x/minute (regular, enoughi in depth, retraction (-))
Pulse rate : 88x/minute (regular, enough tone and volume)
Blood pressure : 130/80 mmHg
Temperature : 36,8o C (Axiller)
VAS :5
◦ General status
Eye : Conjunctiva anemic (-/-)
Nose : rhinorrhage (-/-), rhinorhea (-/-), injury (-), deformity (-)
Ear : otorrhage (-/-), otorrhea (-/-), othematome (-/-), injury (-)
Mouth : cyanotic lips (-), dry lips (-), injury (-), bleeding (-)
 Neck : Injury (-), trachea deviation (-)
Chest
Lung
Inspection : symetric at static and dynamic, no injury, no retraction
Palpation : tactile fremitus was equal on both side
Percussion : sonor on all area
Auscultation : vesicular breath sound (+/+), no additional breath sound
Heart
Inspection : Ictus cordis was not seen
Palpation : palpable Ictus cordis at 5th ICS, 2 cm medial LMCS
Percussion : normal configuration
Auscultation : heart sound normal, reguler, no gallop, no murmur
Abdominal
Inspection : flat, injury mark (-), bowel pattern/movement unseen
Auscultation : bowel soung (+) normal
Palpation : tenderness (-), liver and spleen not palpable
Percussion : tympani, liver dullness (+), shifting dullness (-)
Extremitas Superior Inferior
Cyanosis -/- -/-
Cold Acral -/- -/-
Capillary Refill Time <2”/<2” < 2”/<2”
◦ Local Status (regio left shoulder)
Look : redness (-), swelling (+) in the middle clavicle regio, deformity (+) in
the middle clavicle regio, bleeding (-), vulnus (-)
Feel : tenderness (+), crepitation (-), bone irregularity (+), brachial pulse
(+), sensoric sensation (+), hipesthesi (-)
Move : flexion-extention of the finger (+), dorso-palmar flexion of the wrist
(+), flexion-extention and pronation-supination elbow (+), limited
shoulder movement due to pain
IV. CLINICAL PRESENTATION

V. CLINICAL DIAGNOSIS
Suspect closed fracture of the left clavicle

VI. INITIAL PLAN

• Ip Dx S:-
O : routine blood test, X photoAP and lateral of left shoulder, Xphoto
thorax
• Ip Tx:
– wound toilet
– figure of eight application
– Ringer lactat infussion 20 dpm
– Ketorolac 1 amp/8 hours intravenous injection
• Ip Mx :
Pain, wound condition
• Ip Ex :
 Giving information about patient condition which his clavicle bone was broke
and asking consent for hospitalisation in preparation of further correction by
doing surgical procedure in order to repair bone position.

VII. RADIOLOGY
 There is bone dyscontinuity of clavicula sinistra at 1/3 middle shaft, surrounded by
soft tissue swelling

VIII. DIAGNOSIS
Complete closed fracture of clavicula sinistra 1/3 middle shaft non complicata

IX. TREATMENT
Pro Open Reduction Internal Fixation