Duty Report

(9th Des 2019)

Balqis
Melisa
 Dokter Jaga Patient
Trauma = 1 patient
dr. Sandy Non-Trauma = 0 patient
Admitted = 0 patient

Name Age Diagnosis

An. A 16 yo Vulnus Laceratum at Regio Manus
Sinistra
1st case
Identity & History

Name An. A Past Medical History:

Sex Male (-)
Age 16 y/o

Family History:
(-)
Other complaints:
Chief complaint:
Pain
Perdarahan karena senjata
tajam
 HISTORY OF PRESENT ILLNESS

30 minutes before accident,the patient had gathered at the rail train area with his
friends. Suddenly, a group from different schools came carrying a sickle.then they
attacked him with a sickle. When he was attacked, he tried to hold his face froem
being stabbed gy sickle with his left palm. Then, the sickle stabbed in left palm
and his palm has been bleeding
 Biomechanism of Trauma

06.30 pm
30 mins
IGD
(before
RSUD
admitted)
IGD Koja

Patient was immediately

30 minutes before accident,the patient brought to RSUD Koja.
had gathered at the rail train area with his Patient complaints
friends. Suddenly, a group from different pain at wound site.
schools came carrying a sickle.then they
attacked him with a sickle. When he was
attacked, he tried to hold his face froem
being stabbed gy sickle with his left
palm. Then, the sickle stabbed in left
palm and his palm has been bleeding
 Primary Survey

Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), cold extremities, BP: 110/80, HR: 96 x/mins, Temp: 36 C, CRT <2 sec
Disability :
GCS (E4M6V5) = 15
Secondary Survey

●Head : bleeding (-), swelling (-), tenderness (-), hematoma (-),

●Eyes : isokor 3mm/3mm, CA (-/-), SI (-/-)
●Nose : hematom (+), edem (+), bleeding (-)
●Ear : normotia, bleeding (-)
●Mouth : bleeding (+), mucosa redness, cyanosis (-),
●Neck : enlargement of lymph nodes (-)
Thorax :
• Inspection : Symmetrical, terdapat jejas di dada kanan
• Palpation : Vocal fremitus & tactile symmetrical
• Percussion : resonance in both lungs
• Auscultation : Vesicular, Rh -/-, Wh -/-; Heart sound I-II normal

Abdomen :
• Inspection : Flat, mass (-),
• Auscultation : Peristaltic sound (+), normoperistaltic
• Palpation : Soft & non tender, distention (-)
• Percussion : Tymphany
 Local state of manus sinistra
• Look: vulnus laceratum at size
4x2cm, active bleeding (+), dasar
otot
• Feel: tenderness(+)
• Move: ROM limited
Oposisi -
Diagnosis and problem

Problems:
Working diagnosis:
Vulnus Laseratum Manus • Pain
Sinistra • Active bleeding
Management
NON SURGERY

Pharmacology
SURGERY
Tetagam 250IU
Ketorolac 30mg
OMZ 40mg
Ceftriaxone inj 1gr

Non-pharmacology
Deep luka
Jahit situasi dengan benang silk