lapjag 24 oktober 2015
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lapjak bedahTRANSCRIPT
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DUTY REPORTSaturday, 24 October 2015
BY:dr. MARISHA FRISKA
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Outpatient : 1
Inpatient : 0
Operation : 0
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IDENTITIYNAME : Mr. A
AGE : 8 Years old
SEX : Male
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PRIMARY SURVEYA : Clear, no airway obstruction
B : Spontaneous, reguler, respiratory rate : 22x/minute
C : Reguler pulse HR =108x/menit, BP= 120/70 mmhg, T = 36.6oC, CRT < 2” Active bleeding from the wound
D : Compos Mentis, GCS 15
E : Vulnus laceratum at regiio Supraorbitalis dextra
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SECONDARY SURVEYANAMNESIS
Autoanamnesis on 24-10-2015 at 09.00
Chief Complain:
Pain on the wound at the right side of forehead after Patient got hit by metal door 30 minutes before admission.
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LOCAL STATUS REGIO SUPRAORBITA DEXTRA
There is vulnus laceratum with size 5 x 2 cm , uneven edges, bone base, with active
bleeding.
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X-ray
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DIAGNOSISVulnus Laceratum regio supraorbita dextra
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TherapyWound toilet
Primary suture
ManagementInj. Cefitaxim
Inj. Ketorolac
Inj. ATS
Inj. TT
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Thank You