Patient List

Admission to
No Identity/Age Diagnose Treatment
ER

5. Mr. Fransyah Budianor/ Admitted at Vulnus morsum serpentis ar Treatment from ER

23 y.o./ 1-42-33-18 00.25 am 23nd pedis sinistra perrish grade 0 • Dressing wound
March 2019 • Inj tetagam
• Patient out by permission
• Po. Asam mefenamat 3x500mg
• Po. Cefadroxil 2x1
• Po. Dexamethason 3x1
 Mr. Fransyah Budianor/ 23 y.o./1-42-33-
18/Admitted at 00.25 am 23nd March 2019

Chief Complain: pain in right foot

History
Patient taken to Ulin hospital because pain in right foot 3 hours before admission. He feel pain in
his right foot because he was bitten by a snake. Dizziness(-), nausea(-), vomit(-), febris(-). The patient
admitted that he saw a snake and the color is black. It was a long snake. But he didn’t see the snak head
shape. He also admitted if this snake is often near his village where he was live.

History of past illness: -

Vital Sign
• GCS : E4V5M6
• BP : 110/60 mmHg
• HR : 97 bpm
• RR : 19 tpm
•T : 37,8o C
• CRT : <3 second
• SpO2 : 96% without O2
Physical Examination
Head/Neck • pale conjungtiva (-/-), sclera icteric (-/-)

• I : symmetric respiratory movement

• P : symmetric VF
Chest • P : sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

• I : distention (-), mass (-)

• A : bowel sound(+) normal
Abdomen • P : tympani(+)
• P : tenderness (-) rebound tenderness (-), muscular rigidity (-)

Extremities • warm (+), edema (-), pale (-)

Clinical Pictures
Diagnosis
Vulnus morsum Serpentis pedis sinistra perrish grade 0
Treatment on ER
• Dressing wound
• Inj tetagam
• Patient out by permission
• Po. Asam mefenamat 3x500mg
• Po. Cefadroxil 2x1
• Po. Dexamethason 3x1