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    Jaga 9 Okt 19

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    Martha Simona
    This duty report summarizes the care of one patient, Mr. T, who is a 20-year-old male brought to the ER after a motorcycle accident. He suffered lacerations to his forehead and cheek along with mild head injury. Upon examination, he was conscious with stable vital signs. Imaging showed no fractures. His diagnosis was lacerations to the forehead and cheek along with mild head injury. His treatment included wound cleaning, antibiotics, pain medication, and consultation with orthopedics for possible surgery.

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    Jaga 9 Okt 19

    Uploaded by

    Martha Simona
    33 views14 pages
    This duty report summarizes the care of one patient, Mr. T, who is a 20-year-old male brought to the ER after a motorcycle accident. He suffered lacerations to his forehead and cheek along with mild head injury. Upon examination, he was conscious with stable vital signs. Imaging showed no fractures. His diagnosis was lacerations to the forehead and cheek along with mild head injury. His treatment included wound cleaning, antibiotics, pain medication, and consultation with orthopedics for possible surgery.

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    jaga 9 okt 19

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    This duty report summarizes the care of one patient, Mr. T, who is a 20-year-old male brought to the ER after a motorcycle accident. He suffered lacerations to his forehead and cheek along with mild head injury. Upon examination, he was conscious with stable vital signs. Imaging showed no fractures. His diagnosis was lacerations to the forehead and cheek along with mild head injury. His treatment included wound cleaning, antibiotics, pain medication, and consultation with orthopedics for possible surgery.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    33 views14 pages

    Jaga 9 Okt 19

    Uploaded by

    Martha Simona
    This duty report summarizes the care of one patient, Mr. T, who is a 20-year-old male brought to the ER after a motorcycle accident. He suffered lacerations to his forehead and cheek along with mild head injury. Upon examination, he was conscious with stable vital signs. Imaging showed no fractures. His diagnosis was lacerations to the forehead and cheek along with mild head injury. His treatment included wound cleaning, antibiotics, pain medication, and consultation with orthopedics for possible surgery.

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    Duty Report 

    9/10/19
    Disusun oleh:

    - sidqi

    - martha

    - Fitri

    - Nur jannah
    Doctor on duty Patients
    dr. Trauma = 1 pasien
    Non-Trauma = 0 pasien

    Name Age Diagnosis


    Mr. T 20 y/o Vulnus excoriasis on frontalis region+
    Vulnus excoriasis on right zygomatical
    region + Mild head injury.
    1. Mr. T/ 20 YRS

    – Chief complain:
    pain on forehead
    – Additional complains:
    dizziness
    History of present illness

    Patient was admitted to ER of Koja Hospital with chief


    complaint pain on fore head 3 hour before admitted to the
    hospital. Patient was ride a motorcycle with moderate speed
    and hit by a car. Patient wore a helmed. There is no loss of
    conciousness but he fainted for 30 minutes after the accident ,
    amnesia retrogard (+), pain (+), and headache (+), nausea and
    vomitting (-), neurological deficits(-), otorhea (-), Rhinorea(-),
    seizurre (-), blurr vision (-).
    Mechanisme of Trauma
    Patient was riding a motorcycle with moderate speed
    PRIMARY SURVEY

    Airway: Airway obstruction causes paradoxical chest and 
    abdominal movements (­). 

    Breathing: symmetrical chest rise with spontaneous 
    breathing, no use of the accessory muscles of respiration.
     
    Circulation: regular heart rate with good pulse volume, 
    warm periphery BP: 110/80mmHg, HR: 84x/menit

    Disability: GCS: E4M6V5
    SECONDARY SURVEY
    Secondary survey

    HEAD :   normocephal, laceration wound on the head of 
    frontalis region
    EYES : PUPIL REACTIVE 3MM/3MM isokor, CA(­/­), SI(­/­)
    NOSE  : NAD 
    EARS : NAD
    MOUTH : PINK, CYANOSIS(­)
    NECK   :  LYMPH NODES NOT PALPAPLE ­
    Thorax – Abdomen 
    Inspection : symmetric chest  – Inspection:  flat, masses (­)
    expantion,effortless respiration, 
    – Auscultation: bowel sound 
    retraction (­) punture wound at 
    upper back over left region. present
    Palpation: tenderness(+),  – Palpation: tenderness(­), 
    weakened vocal  defans muskular(­)
    fremitus,masses(­) – Percussion:­
     Percusion: ­ – Extremities: CRT <2, 
    Auscultation: VS   ICS 5­6 sinistra  edema (­), no deformities 
    . rh(­/­) wh(­/­). BJ I& II reguler. and can move freely
    Localist State
    Look :
    • Vulnus excoriasis on frontalis
    region. Size 4 cm length x 2 cm
    width and swelling and hematome
    at frontalis region. tenderness to
    palpation (+), crepitation (-).

    • Vulnus excoriasis on right


    zygomatical region. Size 4 cm
    length x 3 cm width and swelling
    and hematome at frontalis region.
    tenderness to palpation (+),
    crepitation (-).
    Radiology
    Diagnosis

    – WD
    Vulnus excoriasis on frontalis region+ Vulnus excoriasis on
    right zygomatical region + Mild head injury.

    – DD:
    Fracture impressi os frontalis
    Fracture Basis Cranii
    Moderate Head Injury
    Problems

    – Pain on forehead
    – Swelling on forehead
    – History of loss conciosuness
    Treatment
     Surgery: consult an orthopaedic

     Pharmacology

    - Wound cleaned with NaCl 0,9%, povidone iodine,

    - TIG (250IU,IM)

    - Ceftriaxone 1g inj

    - Ketorolac inj 30mg.


    –ThankYou

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