Professional Documents
Culture Documents
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.
X-ray
DIAGNOSIS
Vulnus Laceratum regio supraorbita dextra
Therapy
Wound toilet
Primary suture
Management
Inj. Cefitaxim
Inj. Ketorolac
Inj. ATS
Inj. TT
Thank You