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