DUTY REPORT

Monday, October 4th 2019

Ranny Ayu Farisah

Nora Saputri
Martha Simona
Nurjanah
dr. Rizky Trauma: 2 patients
Non trauma: 0 patient
Warded: 2 patients

Name Age Diagnosis

An. G 15 y.o Vulnus laceratum regio

antebrachii sinistra
Case #1
 Identity & history
Name Child G
Age 15 years old
Examination date 4 October 2019

Chief complaint: Other complaints:

Pain and open wound of Swelling and bleeding on
left arm 1 hour before Regio antebrachii sinistra
admitted to the hospital.
 History of present illness
1 hour before being admitted to the hospital, patient injury himself with a knife.
He did that because he had rejected by a girl. Right after he did that his mother
found him and bought him to the hospital immediately.

Past medical history: -

Family history: -
Biomechanism of trauma

1 hour
before
admitted

Patient in his Right after that Patient brought

house trying to his mother found him to the
injury himself him and hospital
 Primary survey
Airway
• Airway obstruction (-)
• Patient can speak

Breathing Tanda vital

LOC: composmentis
• Symmetrical chest, chest movements (+), retraction (-), RR:
20x/minutes GCS: 15
Tension: 110/70 mmHg
Heart rate:74x/minutes
Circulation Respiration rate: 20x/minute
• Pulse (+) reguler, warm extremities, cyanosis (-), HR: Temperature: 36.7 C
74x/minutes, CRT <2 sec

Disability
• GCS (E4V5M6) = 15
Secondary survey
• Head : normocephal
• Mata : pupil isokor, CA -/-, SI -/-
• Hidung : epistaksis (-), rinore (-)
• Telinga : bleeding (-), otore (-)
• Mulut : normal mucosa, cyanosis (-)
• Leher : Enlargement of Lymph Node (-)

Thorax Abdomen
Inspection: symmetrical, chest movements Inspection: dflat, mass (-), lesion (-)
(+), lesion (-) Auscultation: peristaltic sound (+), normoperi
Palpation: Tactile fremitus and vocal symetric, staltic
crepitation (-) Palpation: tenderness pain (-), distention (-)
Percussion: sonor in both lungs Percussion: tympany
Auscultation: vesicular, Rh -/-, Wh -/-,
BJ I-II reguler
Local status
Open wound of region antebrachii sinistra. Size: 10
cm length x 2 cm width x 1 cm depth. Dirty wound.
Edge: reguler. Base of wound: soft tissue layer
Working diagnosis

Vulnus laceratum regio antebrachii sinistra

Management
Surgery Non surgery
Hecting ligation Ceftriaxone 2x1g
Ketorolac 3x30mg
TIG 250 IU/IM
Thank you!