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lapjak bedah
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DUTY REPORTSaturday, 24 October 2015
BY:dr. MARISHA FRISKA
Outpatient : 1
Inpatient : 0
Operation : 0
IDENTITIYNAME : Mr. A
AGE : 8 Years old
SEX : Male
PRIMARY SURVEYA : Clear, no airway obstruction
B : Spontaneous, reguler, respiratory rate : 22x/minute
C : Reguler pulse HR =108x/menit, BP= 120/70 mmhg, T = 36.6oC, CRT < 2” Active bleeding from the wound
D : Compos Mentis, GCS 15
E : Vulnus laceratum at regiio Supraorbitalis dextra
SECONDARY SURVEYANAMNESIS
Autoanamnesis on 24-10-2015 at 09.00
Chief Complain:
Pain on the wound at the right side of forehead after Patient got hit by metal door 30 minutes before admission.
LOCAL STATUS REGIO SUPRAORBITA DEXTRA
There is vulnus laceratum with size 5 x 2 cm , uneven edges, bone base, with active
bleeding.
X-ray
DIAGNOSISVulnus Laceratum regio supraorbita dextra
TherapyWound toilet
Primary suture
ManagementInj. Cefitaxim
Inj. Ketorolac
Inj. ATS
Inj. TT
Thank You