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Patient List

No Identity Admission to ER Diagnosis Planning

2. Mr. Fahrudin/ 23 12th May 2019 at Multiple Vulnus Excoriatum at Treatment at ER


y.o/1428104/ 09.15 am regio right Genu, right Cruris, • Wound Toilet
and right Pedis • Po. Mefenamic Acid
3x500mg
• Po. Ranitidin 2 x 150mg
• Gentamicin zalf
• Patient out by permission
2. Mr. Fahrudin/ 23 y.o/1428104/
admitted 12th May 2019 at 09.15 am

Chief Complain: Pain In foot and knee


History taking
Patients present with complaints of foot and knee injuries, this is felt by the
patient since 1 hour before entering the hospital, after the patient has had an
accident in Trikora banjarbaru, a single accident occurs when the patient is
avoiding a hole and the patient falls to the left and the patient's leg is caught
engine, the patient uses a helmet. The patient can still walk, the right toes can
still be in motion, foot tingling (-). There is no decrease in consciousness (-)
nausea and vomiting (- / -) headache (-), seizures (-), double control (-)
History of Past Illness : (-)
History of Family Illness : (-)
Primary Survey
• Airway :
– Clear with C-Spine control
• Breathing :
– Lesion (-), symmetrical chest movement, tracheal deviation (-), jugular vein
distension (-), RR : 18x/minute (regular), Vesicular breath sound both side. SpO2 :
98% without O2.
• Circulation :
– Pulse : 87x/minute (strong, regular), BP : 110/70 mmHg, active bleeding (-).
• Disability :
– GCS E4V5M6, pupils equal 3 mm/3 mm, direct light reflex (+/+), indirect light
reflex (+/+), lateralization (-/-), BO (-/-), BR (-/-), BS (-/-), BH (-/-).
Secondary Survey
• Allergy : (-)
• Medication : (-)
• Past Illness: (-)
• Last Meal : 03.00 am
• Environment : Trikora Banjarbaru
• Eye : sclera icteric (-), pale conjungtiva (-/-), pupil equal (3mm/3mm), lights reflex (+/
+), subconjuntiva bleeding (-|-)
Head & Neck • bloody rinorrhea (-/-), bloody otorrhea (-/-)
• enlargement lymph node (-), lesion (-), edema (-|-)

• I : symetric respiratory movement, retraction (-), bruise (-)


Chest • P : sonor at all lung fields
• A : VBS, ronchi (-/-), wheezing (-/-)

• I : distension (-), lesion (-), bruise (-)


• A : bowel sound (+) 6x/minutes
Abdomen • P : soft, defense muscular (-) tenderness hard to evaluate, liver and spleen not
palpable
• P : tympani at all region

Extremities • Cold extremities (+), edema (-|-), lateralization (-/-)


Clinical Picture
Clinical Picture
Diagnosis
• Multiple Vulnus Excoriatum at regio right Genu, right Cruris,
and right Pedis
Management
Treatment in ER :
• Wound Toilet
• Po. Mefenamic Acid 3x500mg
• Po. Ranitidin 2 x 150mg
• Gentamicin zalf
• Patient out by permission