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DUTY REPORT

Saturday, 24
October 2015
BY:
dr. MARISHA FRISKA

Outpatient: 1
Inpatient : 0
Operation : 0

IDENTITIY
NAME

: Mr. A

AGE

: 8 Years old

SEX

: Male

PRIMARY SURVEY
A : Clear, no airway obstruction
B : Spontaneous, reguler, respiratory rate : 22x/minute
C : Reguler pulse HR =108x/menit, BP= 120/70 mmhg, T =
36.6oC, CRT < 2 Active bleeding from the wound
D : Compos Mentis, GCS 15
E : Vulnus laceratum at regiio Supraorbitalis dextra

SECONDARY SURVEY
ANAMNESIS
Autoanamnesis on 24-10-2015 at 09.00
Chief Complain:
Pain on the wound at the right side of forehead
after Patient got hit by metal door 30 minutes
before admission.

LOCAL STATUS REGIO


SUPRAORBITA DEXTRA
There is vulnus
laceratum with size 5 x
2 cm , uneven edges,
bone base, with active
bleeding.

X-ray

DIAGNOSIS
Vulnus Laceratum regio supraorbita dextra

Therapy
Wound toilet
Primary suture

Management
Inj. Cefitaxim
Inj. Ketorolac
Inj. ATS
Inj. TT

Thank You

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