23 Juni 2017

DM. Rita, DM. Claudya, dan DM Ika

 Name : Mr. SN
Age : 18 years old
Sex : Male
Address : Tofa
 Chief Complaint : Wound on face, head and extremity
MOI ( Autoanamnesis and heteroanamnesis)
Patient come to the emergency unit with wounds on his
face, head and extremity after he got a motorcycle accident.
The mechanism of injury was clear, he said he crashed the
electro pillar. His family said that he was drunk when he ride
the motorcycle. The patient didnt wear a helmet. Pain in
wounds location (+), Headeche (-), dizziness (-), nausea
and vomiting (-), unconsciousness (-), seizures (-).
 A: clear
B : RR: 21 times in a minute
C : Blood preasure : 120/70 mmHg , Pulse: 92 times/minute,
reguler.
D : GCS E4V5M6, pupil ishokor, 3mm/3mm
E : Vulnus laceratum regio periorbital sinistra
Vulnus laceratum regio parietal
Vulnus Eskoriatum regio deltoid sinistra
Vulnus Eskoriatum regio antebrachi sinistra
Vulnus Eskoriatum regio genue sinistra
 Head : vulnus laceratum regio parietal
Eye : vulnus laceratum regio periorbital sinistra, anemic (-/-), pupil
isokor (+/+), icteric (-/-)
Ear : blood clot(-), ottorea (-/-)
Nose : blood clot (-), rhinnorea (-/-)
Mouth : blood clot (-)
 Inspection : chest expansion bilateral simetric, pattern of
respiration is abdominothoracal
Palpation : vocal fremitus R=D
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-), wheezing (-/-)
 Inspection : flat (+)
Palpation : distended (-) , tenderness pain (-), mass (-)
Percusion : timpany sound (+)
Auscultation : peristaltics (+) still normally
 Look :
Vulnus Eskoriatum regio deltoid sinistra
Vulnus Eskoriatum regio antebrachi sinistra
Vulnus Eskoriatum regio genue sinistra
Feel : pain in wound location (+)
Move : movement hands and foots was freely
 Vulnus Laseratum regio periorbital
 Vulnus laceratum regio periorbital sinistra
Vulnus laceratum regio parietal
Vulnus Eskoriatum regio deltoid sinistra
Vulnus Eskoriatum regio antebrachi sinistra
Vulnus Eskoriatum regio genue sinistra
 Head Up 30 degree
O2 2 lpm canul nasal
IVFD NS 500 cc 20 tpm
Inj. Ketorolac 1 x 1 amp/iv
Inj. Ranitidin 2 x 1 amp/iv
Wound toilet
Hecting
Diet soft food
 Name : Mr. RN
Age : 25 years old
Sex : Male
Address : Tofa
 Chief Complaint : Wounds on hand and foot
MOI ( Autoanamnesis and heteroanamnesis)
Patient come to the emergency unit with wounds on his hand
and foot after he got a motorcycle accident. The mechanism of
injury was clear, he said his sitting behind on the motorcycle
that crashed the electro pillar and only gots some scar after
sliping on the road. His family said that he was drunk too.The
patient didn't wear a helmet. Pain in wound location (+),
headache (-), dizziness (-), nausea and vomiting (-)
unconciousness (-) seizure (-).
 A: clear
B : RR: 20 times in a minute
C : Blood preasure : 130/90 mmHg , Pulse: 96 times/minute,
reguler.
D : GCS E4V5M6, pupil ishokor, 3mm/3mm
E : Vulnus Eskoriatum regio ventral dan dorsal antebrachi
dextra and sinistra
Vulnus Eskoriatum regio genue dextra and sinistra
 Head : normal
Eye : anemic (-/-), pupil isokor (+/+), icteric (-/-)
Ear : blood clot(-), ottorea (-/-)
Nose : blood clot (-), rhinnorea (-/-)
Mouth : blood clot (-)
 Inspection : chest expansion bilateral simetric, pattern of
respiration is abdominothoracal
Palpation : vocal fremitus R=D
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-), wheezing (-/-)
 Inspection : flat (+)
Palpation : distended (-) , tenderness pain (-), mass (-)
Percusion : timpany sound (+)
Auscultation : peristaltics (+) still normally
 Look :
Vulnus Eskoriatum regio ventral dan dorsal antebrachi dextra and
sinistra
Vulnus Eskoriatum regio genue dextra and sinistra
Feel : pain in wound location (+)
Move : movement hands and foots was freely
Multiple Vulnus ekskoriatum
 Wound toilet