Duty Report

(3rd Dec 2019)

Wan Nor Syazana

Nur Hayani
 Dokter Jaga Patient
Trauma = 1 patient
dr. Kellina Non-Trauma = 0 patient
Admitted = 1 patient

Name Age Diagnosis

Mr. LH 52 yo Vulnus laceratum on regio
supraaorbital.
1st case
Identity & History

Name Mr. LH Past Medical History:

Sex Male Stroke (+)
Age 52 y/o HT(+)

Family History:
(-)
Chief complaint:
Pain at the eyebrow Other complaints:
Bleeding (+)
 HISTORY OF PRESENT ILLNESS

Three hours before admitted, the patient was at home when suddenly he fell
down from his bed with his face hit the ground. There was an active bleeding at
the regio supraaorbital. Due to the incident, there’s laceration at the regio
supraaorbital.
 Biomechanism of Trauma

18:30 pm
15:30 pm
IGD
(before
RSUD
admitted)
IGD Koja

Patient was brought to

RSUD Koja.
Patient complaints
.
Three hours before admitted, pain at wound site.
the patient was at home
when suddenly he fell down
from his bed with his face hit
the ground. There was an
active bleeding at the regio
supraaorbital. Due to the
incident, there’s laceration
at the regio supraaorbital.
 Primary Survey

Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 22 x/mins
Circulation :
Pulse (+, regular), warm extremities, BP: 168/110 mmHg, HR: 96 x/mins, Temp: 36,9 C, CRT <2 sec
Disability :
GCS (E4M6V5) = 15
Secondary Survey

●Head : bleeding (-), swelling (-), tenderness (-), hematoma (-),

●Eyes : eyebrow bleeding (+), isokor 3mm/3mm, CA (-/-), SI (-/-)
●Nose : hair nose (-), bleeding (-)
●Ear : normotia, bleeding (-)
●Mouth : mucosa redness, cyanosis (-)
●Neck : enlargement of lymph nodes (-)
Thorax :
• Inspection : Symmetrical
• Palpation : Vocal fremitus & tactile symmetrical
• Percussion : resonance in both lungs
• Auscultation : Vesicular, Rh -/-, Wh -/-; Heart sound I-II normal

Abdomen :
• Inspection : Flat, mass (-),
• Auscultation : Peristaltic sound (+), normoperistaltic
• Palpation : Soft & non tender, distention (-)
• Percussion : Tymphany
Local state of supraaorbital
region
• Look: Vulnus laserasi on eyebrow
with irregular edge, 3x1cm, base of
wound: dermis, active bleeding (+)

• Feel: tenderness (+) normal facial

sensory, oedema (+), crepitation (-)

• Move: Normal ROM of cervical.

Diagnosis and problem

Problems:
Working diagnosis:
Vulnus laceratum on regio • Pain
supraaorbital • Bleeding
Management

NON SURGERY
SURGERY
Pharmacology
Consult plastic surgeon
Ketorolac inj 3x30mg
OMZ inj 2x40mg
Ceftriaxone inj 2x1gr
Tetanus Toxoid

Non-pharmacology

Wound closure