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Mr A ( 34 YO)Mekanisme of the trauma :motorcycle crash Injury of target organ : regio labialis posteriorSymptoms and signs : pain on the bruiseTransport : by car
PRIMARY SURVEYAirway : clear ( no snoring, no gargling, no stridor) conclusion : clear.
Breathing :Inspeksi : bruise -, chest wall movement symmetrical, RR 20x/min, hematom –Palpasi : crepitation – pain (-)Perkusi : sonor right = leftAuskultasi : basic breath sound vesikuler
HISTORY OF ILNESS±30 minute before enter to hospital patient have an motorcycle accident. when patients are riding motorcycles fast and heavy rain, and the patient's motor slip hit car in front. patient could not avoid the sudden stop. patients eventually fell and bloody lip patients because a tear. no head injury, no collision chest, no fainting, no amnesia, no vomiting, no nausea.
PRIMARY SURVEYC : warm extremities, Pulse = 82 x/mnt , BP: 120/80mmHg, Temp= 360C, capillary refill <2”
Conclusion : no sign of shock
PRIMARY SURVEYDisability
GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm, centered, direct light reflex/indirect light reflex +/+
Exposure no life-threatening injury
Secondary Survey Chief complaint : pain on the bruise Additional complaint : weakness
SECONDARY SURVEY
HEAD TO TOE
regio frontalis dextraLook : vulnus eksoriasi(+), jejas (+), edema (-)Feel : pain (+) , crepitation (-)Move : dorso flexi +, anteflexi +, abduksi +,
adduksi +
SECONDARY SURVEYEyes : Pupil circular, isochoric
3mm/3mm, conjuntiva anemis -/-, sclera icteric -/-
Ear : secret -/-, blood -Nose : secret -/-, blood -Neck : bruise - , hematom -
Thorax :Insp : movement of chest wall
symmetrical Pal : vocal fremitus right = left Per : sonor right = left Aus : vesiculer, rhonki -/-, wheezing
-/-
Abdomen :Ins : flat, bruise (-), mass (-)Aus : bowel sound (+) 4times/minutePal : tenderness (-)Per : tympani, percussion pain (-) Ekstremitas : warm extremities, cap. refill < 2”, edema (-)
DIAGNOSIS
CKR + Vulnus laceratum
TREATMENT
Patient not hospitalized Wound toilet Hecting Observasi
Medication Analgetic Antibiotic
3. Mr H ( 21 YO)Mekanisme of the trauma : accident a suicide
attempt Injury of target organ : Regio antebrachii
sinistraSymptoms and signs : pain on the bruiseTransport : by motorcycle
HISTORY1 hour before to hospital, the
patient had an accident a suicide attempt for arguing with his girlfriend, patients slashing his left hand with a razor blade to cause open sores and bleeding. before the patient was taken to the clinic, but only wound bandaged it. eventually the patient to the hospital uki.
PRIMARY SURVEY Airway : clear ( no snoring, no gargling, no stridor) conclusion : clear.Breathing : Inspeksi : bruise -, chest wall movement
symmetrical, RR 24x/min, hematom – Palpasi : crepitation – Perkusi : sonor right = left Auskultasi : basic breath sound vesikuler
PRIMARY SURVEYCirculation : warm extremities, Pulse = 82 x/mnt , BP: 140/100mmHg, Temp= 360C, Respiration Rate : 24x/menit, capillary refill <2”
Conclusion : no sign of shock
PRIMARY SURVEY Disability
GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm, centered, direct light reflex/indirect light reflex +/+
Exposure
no life-threatening injury
Secondary Survey Chief complaint : pain and bleeding
on the bruise Additional complaint : weakness
Status localis 1. Regio antebrachiiLook : jejas (+), bruise (+), bleeding (+), edema (-)Feel : pain in woundMove : flexi +, anteflexi +, abduksi +, adduksi +
Eyes : Papil circular, isochoric 3mm/3mm,conjuntiva anemis -/-, sclera icteric -/-
Ear : secret -/-, blood -Nose : secret -/-, blood -Neck : bruise - , hematom
-
Thorax :Insp : movement of chest wall
symmetrical Pal : vocal fremitus right = left Per : sonor right = left Aus : vesiculer, rhonki -/-, wheezing
-/-
Abdomen :Ins : flat, bruise (-), mass (-)Aus : bowel sound (+) 4 times/minutePal : tenderness (-)Per : tympani, percussion pain (-) Ekstremitas : warm extremities, cap. refill < 2”, edema (-)
DIAGNOSIS
Vulnus Lacseratum e.c sharps
TREATMENT
Patient pro hospitalized Wound toilet Hecting
Medicamentosa- Analgetic- Antibiotic