No.Name : Mr. A Sex : male

Age : 18 years old No. Reg : 628051

Main complaint : Wound on the foot

Case : The condition had suffered for 1 hours before the patient taken to the hospital. There was no history loss of consciousness and no vomiting.

Mechanism of injury

: He was walking on the street without sandal, then accidentally his right foot punctured by a rusty nail.

Sustained injury : Right FootSymptom & sign : woundExamination : Physical examination

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Primary SurveyPrimary Survey

A: Clear

B: RR : 22x/minutes, spontaneous, symmetric, thoraco abdominal type

C: BP : 120/80 mmHg, PR : 84x/minute, regular, adequate

D: GCS 15 (E4M6V5), pupil equal Ø 2,5 /2,5 mm, Light Reflex +/+

E: T (ax) : 36,5 oC

Secondary SurveySecondary Survey

Right Plantar region :I : Seen punctured wound size 1x0,5 cm. Edema (-)P : Crepitation (-)

WORKING DIAGNOSIS : - Vulnus ictum at right plantar region

MANAGEMENT : • Medicament• Proceed Wound Care• Patient discharge