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  • Bed Site Teaching Mesfa Juniny TUTOR: DR - Rizal Daulay, SP - OT

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    Mr. A.roni, a 45-year-old gardener, presented to the emergency room with bleeding from a stab wound to his right leg. He reported being stabbed once by someone he knew 3 hours prior while sitting in his garden. At a local clinic, the wound was sutured but the bleeding did not stop, so he was brought to the ER. On physical examination, he had an active bleeding wound on his right leg measuring 7cm by 1cm by 15cm deep, penetrating from the front of the leg to the back. The diagnosis was a puncture wound to the right leg region.

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    BST MESFA

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    Mr. A.roni, a 45-year-old gardener, presented to the emergency room with bleeding from a stab wound to his right leg. He reported being stabbed once by someone he knew 3 hours prior while sitting in his garden. At a local clinic, the wound was sutured but the bleeding did not stop, so he was brought to the ER. On physical examination, he had an active bleeding wound on his right leg measuring 7cm by 1cm by 15cm deep, penetrating from the front of the leg to the back. The diagnosis was a puncture wound to the right leg region.

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    9 views11 pages

    Bed Site Teaching Mesfa Juniny TUTOR: DR - Rizal Daulay, SP - OT

    Uploaded by

    perda
    Mr. A.roni, a 45-year-old gardener, presented to the emergency room with bleeding from a stab wound to his right leg. He reported being stabbed once by someone he knew 3 hours prior while sitting in his garden. At a local clinic, the wound was sutured but the bleeding did not stop, so he was brought to the ER. On physical examination, he had an active bleeding wound on his right leg measuring 7cm by 1cm by 15cm deep, penetrating from the front of the leg to the back. The diagnosis was a puncture wound to the right leg region.

    Copyright:

    © All Rights Reserved
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    of 11

    BED SITE TEACHING

    MESFA JUNINY
    TUTOR : dr.Rizal Daulay,Sp.OT

    CASE REPORT
    IDENTIFICATION

    Name : Mr. A.roni


    Sex : Male
    Age : 45 Years Old
    Address: Tanjung Margo
    Status : Married
    Occupation : Gardener
    Religion : Moslem

    ANAMNESIS (Autoanamnesis)
    Chief of complain

    os came because of bleeding on the right leg as a result of stab


    wounds

    History of illness

    About 3 hours before he arrives at the hospital, os admitted


    stabbed by someone he knew with a knife, one time. He
    mentioned that he got a puncture when he was in a sitting
    position in the garden.

    Immediately after the incident, os taken to a local clinic and


    claimed to have sewn. but because the bleeding does not stop,
    os taken to the ER of rsmp

    PHYSICAL EXAMINATION

    General examination
    General condition
    : sick
    Sickness condition
    : moderate sickness
    Consciousness
    : compos mentis
    Blood pressure
    : 110/70 mmHg
    Pulse rate
    : 88 times/minute,
    regular
    Respiration rate
    : 24 times/minute
    Temperature
    : 36,3 0 C

    Spesific examination

    Inspection
    Penetrating injuries on region cruris dextra
    active bleeding (+)
    the size of the wound : P : 7cm L: 1cm T : 15cm
    (Penetrating injuries of cruris anterior to cruris
    posterior)

    Spesific examination
    Look : deformity (-), atrophy (-), Discolouration (-),
    Swelling (+), scars (-).
    Feel : swelling (-)
    Move : ROM active and NVD: good.

    Diagnosis
    v. punctum on region cruris dexttra

    THANK YOU

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