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    Lapjag 3 Dec 2019

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    syazana salim
    This document summarizes a duty report from the 3rd of December 2019 at Koja Hospital. It describes a 52-year-old male patient, Mr. LH, who was admitted with a laceration to his eyebrow region after falling from his bed and hitting his face on the ground. The report details the patient's history, examination findings, diagnosis of a lacerated wound, and management which included wound closure by the plastic surgeon and medications.

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    Lapjag 3 Dec 2019

    Uploaded by

    syazana salim
    33 views15 pages
    This document summarizes a duty report from the 3rd of December 2019 at Koja Hospital. It describes a 52-year-old male patient, Mr. LH, who was admitted with a laceration to his eyebrow region after falling from his bed and hitting his face on the ground. The report details the patient's history, examination findings, diagnosis of a lacerated wound, and management which included wound closure by the plastic surgeon and medications.

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    This document summarizes a duty report from the 3rd of December 2019 at Koja Hospital. It describes a 52-year-old male patient, Mr. LH, who was admitted with a laceration to his eyebrow region after falling from his bed and hitting his face on the ground. The report details the patient's history, examination findings, diagnosis of a lacerated wound, and management which included wound closure by the plastic surgeon and medications.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    33 views15 pages

    Lapjag 3 Dec 2019

    Uploaded by

    syazana salim
    This document summarizes a duty report from the 3rd of December 2019 at Koja Hospital. It describes a 52-year-old male patient, Mr. LH, who was admitted with a laceration to his eyebrow region after falling from his bed and hitting his face on the ground. The report details the patient's history, examination findings, diagnosis of a lacerated wound, and management which included wound closure by the plastic surgeon and medications.

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    Duty Report

    (3rd Dec 2019)

    Wan Nor Syazana


    Nur Hayani
    Dokter Jaga Patient
    Trauma = 1 patient
    dr. Kellina Non-Trauma = 0 patient
    Admitted = 1 patient

    Name Age Diagnosis


    Mr. LH 52 yo Vulnus laceratum on regio
    supraaorbital.
    1st case
    Identity & History

    Name Mr. LH Past Medical History:


    Sex Male Stroke (+)
    Age 52 y/o HT(+)

    Family History:
    (-)
    Chief complaint:
    Pain at the eyebrow Other complaints:
    Bleeding (+)
    HISTORY OF PRESENT ILLNESS

    Three hours before admitted, the patient was at home when suddenly he fell
    down from his bed with his face hit the ground. There was an active bleeding at
    the regio supraaorbital. Due to the incident, there’s laceration at the regio
    supraaorbital.
    Biomechanism of Trauma

    18:30 pm
    15:30 pm
    IGD
    (before
    RSUD
    admitted)
    IGD Koja

    Patient was brought to


    RSUD Koja.
    Patient complaints
    .
    Three hours before admitted, pain at wound site.
    the patient was at home
    when suddenly he fell down
    from his bed with his face hit
    the ground. There was an
    active bleeding at the regio
    supraaorbital. Due to the
    incident, there’s laceration
    at the regio supraaorbital.
    Primary Survey

    Airway :
    Airway obstruction (clear)
    Breathing :
    Spontaneous breathing (+), retraction (-), RR: 22 x/mins
    Circulation :
    Pulse (+, regular), warm extremities, BP: 168/110 mmHg, HR: 96 x/mins, Temp: 36,9 C, CRT <2 sec
    Disability :
    GCS (E4M6V5) = 15
    Secondary Survey

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


    ●Eyes : eyebrow bleeding (+), isokor 3mm/3mm, CA (-/-), SI (-/-)
    ●Nose : hair nose (-), bleeding (-)
    ●Ear : normotia, bleeding (-)
    ●Mouth : mucosa redness, cyanosis (-)
    ●Neck : enlargement of lymph nodes (-)
    Thorax :
    • Inspection : Symmetrical
    • 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 supraaorbital
    region
    • Look: Vulnus laserasi on eyebrow
    with irregular edge, 3x1cm, base of
    wound: dermis, active bleeding (+)

    • Feel: tenderness (+) normal facial


    sensory, oedema (+), crepitation (-)

    • Move: Normal ROM of cervical.


    Diagnosis and problem

    Problems:
    Working diagnosis:
    Vulnus laceratum on regio • Pain
    supraaorbital • Bleeding
    Management

    NON SURGERY
    SURGERY
    Pharmacology
    Consult plastic surgeon
    Ketorolac inj 3x30mg
    OMZ inj 2x40mg
    Ceftriaxone inj 2x1gr
    Tetanus Toxoid

    Non-pharmacology

    Wound closure

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