LAPORAN KASUS

Dokter Muda:
I Nyoman Arep Kusuma Negara (2171121088)
Pembimbing :
dr. Fidella Dary Raizza
Patient’s Identity
Name : JCM
Date of Birth : 11th October 1993
Age : 20 years old
Gender : Female
Contact number : -
Address in Bali : Sampan Ubud
Patient’s History
A 20-years-old patient came to Ubud OMSA medic on 27 th April 2023 with
complaints of scratch wound on his left leg. The wound was caused by being
scratched by a dog since 30 minutes before comes to OMSA Medic. The
wound on the patient’s left leg is reported don’t have active bleeding just
licked by dog after scratched on it. The patient's wound is not too big and not
deep. The patient said that he was bitten by a dog when he was walking on
the road. The wound has been washed with water. The patient has no history
of rabies vaccination before and the patient has not taken any medication
before. Other complaints such fever denied by patient.
Patient’s History
o Past illness history :
There isn’t the same history disease before. Patient denied all of chronic disease like
hypertension, diabetes mellitus, and cardiac disease. Allergic history denied by patient.

o Family illness history :

The patient denied all of chronic disease like hypertension, diabetes mellitus, and
cardiac disease in his family.

o Personal, social, and environmental history :

The patient is a tourist and stay in Ubud with her family for holiday.
Physical Examination
o STATUS PRESENT

General Appearance : Well

Consciousness : Compos Mentis (E4V5M6)
Blood Pressure : 110/80 mmHg
Heart Rate : 78x/minutes, regular
Respiration : 16x/minutes, regular
Temperature : 36,0℃
Oxygen Saturation : 97% on air
Physical Examination
o STATUS GENERAL

Eyes : Icteric sclera (-/-), anemic conjunctiva (-/-), pupils

reflex (+/+) , sunken eyes (-/-)
ENT : Ear : normal; Nose: hyperemic (-), mucus (-); Throat:
hyperemic (-), Tonsil T1/T1
Neck : Lymphnode enlargement (-)
Chest and Lungs : Vesicular (+/+), wheezing (-/-), rhonchi (-/-)
Cardiovascular : S1 S2 single regular, gallop (-), murmur (-)
Physical Examination
o STATUS GENERAL

Abdomen : Soft, no distention, bowel sound (+) normal, tenderness (-) in

all region. Liver and spleen impalpable.
Extremities : No gross deformities, no cyanosis, no edema
Skin : Good skin turgor, CRT < 2 second, warm, no pallor
Physical Examination
Localized Status
• Localized state left leg on posterior side (S): superficial wound with
scratch mark, non intact skin (Laseceration (+) minimal), tenderness (+).
ASSESMENT
• Vulnus Morsum ec Dog Bite (Wound Category II WHO)

TREATMENT
• Wound care (Wash the wound with NaCl 0.9% for 10 minutes, give betadine and alcohol)
• Verorab (Rabies Vaccine) 0,5ml intramuscular injection on deltoid sinistra and dextra (1x)

RECOMMENDATIONS
• Post exposure Rabies Vaccination (Verorab): 2 dose Vaccination at day 0 (27 April 2023), 1 Vaccination at
day 7 (04 Mei 2023), 1 Vaccination at day 21 (18 Mei 2023).
• Recommend to get rabies immunoglobuline 20 IU per kg body weight within 7 days after first rabies
vaccination (verorab).
• Keep wound dry and clean, observe for secondary sign of infection (redness around wound, warm on
redness, pus from wound). See doctor as soon as possible if there is infection sign ond the wound site.
THANK YOU