DUTY REPORT

Monday, October 4th 2019

Ranny Ayu Farisah

Nora Saputri
Martha Simona
Nurjanah
 dr. Edward Trauma: 3 patients
Non trauma: 0 patient
Warded: 2 patients

Name Age Diagnosis

G 15 y.o Vulnus laceratum regio
antebrachii sinistra
Mrs. A 45 y.o Vulnus laceratum regio
frontalis and cruris
sinistra
A 8 y.o Hemarthrosis
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

• Symmetrical chest, chest movements (+), retraction (-), RR:
LOC: composmentis
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
• Eye : pupil isokor, CA -/-, SI -/-
• Nose : epistaksis (-), rinore (-)
• Ear : bleeding (-), otore (-)
• Mouth : normal mucosa, cyanosis (-)
• Neck : Enlargement of Lymph Node (-)

Thorax Abdomen
Inspection: symmetrical, chest movements Inspection: dflat, mass (-), lesion (-)
(+), lesion (-) Auscultation: peristaltic sound (+),
Palpation: Tactile fremitus and vocal symetric, normoperistaltic
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
Case #2
 Identity & history
Name Mrs. A
Age 45 years old
Examination date 4 October 2019

Other complaints:
Chief complaint:
Fainted
Pain and wound on
Nausea
forehead and leg
Vomitting
 History of present illness
30 minutes before admitted to the hospital, the patient crashed by a car when
she was riding her motorcycle. She was going to turn around then crashed by
a car from the back, then she fell. She was using a helmet and the helmet
didn’t taken off her head. Right after the accident, she was brought to Koja
Hospital. On the way to the hospital, she vomitted once, but no proyectile
vomit. She fainted for a while but then wake up and didn’t faint again. At the
hospital, she could speak well but she wouldn’t open her eyes due to pain.
The patient said she still feel nausea up until the examination.

Past medical history: -

Family history: -
Biomechanism of trauma

30
minutes
before
admitted

Patient was on Patient was going Patient fell and hit Patient brought to
the way to her to turn around, the road Koja Hopital
office then crashed by a
car from the back
 Primary survey
Airway
• Airway obstruction (-)
• Patient can speak

Breathing Tanda vital

• Symmetrical chest, chest movements (+), retraction (-), RR:
LOC: composmentis
20x/minutes GCS: E3V5M6
Blood pressure: 130/80
mmHg
Circulation Heart rate:82x/minutes
• Pulse (+) reguler, warm extremities, cyanosis (-), HR:
Respiration rate: 20x/minute
82x/minutes, CRT <2 sec
Temperature: 36.8 C

Disability
• GCS (E3V5M6) = 14
Secondary survey
• Head : normocephal, open wound (+), no active bleeding
• Eye : pupil isokor, CA -/-, SI -/-
• Nose : epistaksis (-), rinore (-)
• Ear : bleeding (-), otore (-)
• Mouth : normal mucosa, cyanosis (-)
• Neck : Enlargement of Lymph Node (-)

Thorax Abdomen
Inspection: symmetrical, chest movements Inspection: flat, mass (-), lesion (-)
(+), lesion (-) Auscultation: peristaltic sound (+),
Palpation: Tactile fremitus and vocal symetric, normoperistaltic
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 left frontal regio, size 2cm length x
0,5cm width x 0,5cm depth, irregular edge, base of
wound: sof tissue, no active bleeding.

Vulnus excoriatum of left maxillary regio, size 5cm

length x 3cm depth.
Local status
Open wound of medial malleolus of left foot, size
2cm length x 0,5cm width x 0,5cm depth, irreguler
edge, base of wound: soft tissue, no active
bleeding.

Multiple vulnus excoriatum of pedis regio.

There was no limited movements.

Working diagnosis
Vulnus laceratum of frontal and pedis regio
Mild head injury

Problems
- Open wound
- Pain
- Nausea
- Risk of infection
Management
Surgery Non surgery:
Hecting ligation Wound toilet
Asering 12tpm
Ketorolac 30mg
Citicolin 500mg
Tetagam
Thank you!