Duty report

Sunday, January 15th 2017

Surgical resident :

Sumanto, M.D.

Surgical Interns : Anna, Poundra, Qatrin, Yuvi

Attending surgeons in-charge

Pediatric surgery
: Suharyo, M.D. SpB SpBA
Digestive surgery
: Arief Setiawan, M.D. SpBKBD
Orthopaedic surgery
: Bobby N. Nelwan, M.D. SpOT
Plastic & reconstructive surgery
: Guntoro, M.D. SpBPKRE
Neurologic surgery
: Lukman Maruf, M.D., SpBS
Oncologic surgery
: Taslim Mansoer, M.D. SpB(K)Onk
TCV surgery
: Andreas A . Lensoen, M.D., SpBTKV
Urologic surgery
: Haryono, M.D., SpU

Patients resume
Outpatient : 0
Inpatient : 1
Operation : 0

Mr. A., 23 y.o. 845535

Chief Complain : right footwound
History of Present Illness:

2 weeks before admission, when he was riding a

motorcycle, his right foot was hit by a high speeding
car. His right little toe was missing by that accident,
and also there was a skin loss.
No chest nor abdominal injury
Patient went to a hospital at central Bangka where he
had a surgery, after which due to lack of facilities,
hewas referred to the Gatot Subroto Army Central
Hospital.

History of Past Illness:

DM (-)

Physical findings
Primary survey

Airway : clear
Breathing : spontaneous, RR 20x/mnt
Circulation : ABP 110/70 mmHg,HR 78x/mnt
Disability : E4M6V5

Physical findings
Secondary survey
Eye : anemic -/- icteric -/ Thorax : vbs +/+ rales -/ Abdomen : Flat, tenderness -, bowel
sounds + normal, tympanitic
Extremity: edema -, cyanotic -

Local findings
L :raw surface at
dorso-pedal region
with skin graft on the
right side, no pus nor
bleeding, missing
little toe
F : pain (+) NVE
normal
M : limited due to
pain

Laboratory findings
Hgb 14.2 g/dl Hct 41% L 10.360/uL
P 388.000/uL
PT 0.9x aPTT 1.1x
Ur 20 mg/dL Cr 0.9 mg/dL
RBS 101 mg/dL
Na 138 mmol/L K 4.3 mmol/L
Cl 103 mmol/L

Right foot plain PA & Oblique X-ray images

Before internal fixation

After internal fixation

Working diagnosis
Vulnus granulosum at right-foot
5th metatarsal-bone and (4rd toe) fractures
of the right foot (on internal fixation)
Absent left-5th toe

Plan of management

Informed consent
Elective skin graft
Analgesic
Antibiotic

Todayscondition

I would like to extend my appreciation

for your keen attention on this single case.