H/M/30yo

72.22.18
Chief complaint : Lacerated wound on the right elbow
It has been suferred by patient 1 hour before admitted
to Pirngadi Hospital. Previously patient’s right elbow
was scratched by metallic roof plat while he was fixing
roof. History of bleeding (+), pain (+). History of tetanus
immunization was unclear.
 Present State
• Awareness : Alert
• BP : 120/70 mmHg
• HR : 120 x/minute
• RR : 20 x/minute
• Temperature : 36.7˚C
• VAS :4
 Generalized State
• Head : no abnormality was found
• Neck : no abnormality was found
• Thorax : no abnormality was found
• Abdomen : no abnormality was found
• Extremity
– Superior : Lacerated wound on the right elbow
– Inferior : no abnormality found
Localized State :
•Right Elbow :
– L: Lacerated wound o/t right
elbow, with diameter of 3 x
0.5 cm, with regular edge,
subcutis based and minimal
contamination, active
bleeding (-), distance from
right shoulder 25cm, 3 cm
from lateral epicondyle
– F: pain (+), swelling (-)
– M: ROM (+), elbow flexion (+)
normal, elbow extension (+)
normal, Pronation and
supination of elbow (+)
normal
Working Diagnose :
Lacerated Wound o/t (R) Elbow
Treatment at the ER :
•Antibiotic
•Analgetic
•Tetanus Toxoid 1 ml IM
•ATS 3000 iu IM
•Wound toilet + Primary suture