MR 26 Juli Suicide

26 Juli 2013Coass jaga:

Rico RotinggoMargareta J. Sono

ON DUTY REPORT

May 9th 2013 Company Logo

RESUMEIdentity Diagnose Therapy

Mr. WM, 19 y.o. male •Vulnus ictum at regio epigastrium•Susp. Internal bleeding ec abdominal stab wound

- IVFD RL 20 dpm- Wound toilet- Hecting + dressing- Ketorolac 3% 1 amp iv- ATS 1 amp im- Ceftriaxone 2x1 gram iv- Pro laparatomi

exploration

Mr. MT, 18 y.o. male •Vulnus laseratun at regio genu dextra•Open fracture patellad extra•Susp. Fractur femur dextra

- IVFD RL 20 tpm- Wound toilet- Hecting + dressing- Inj. KTC 3% 3x1 amp iv- Inj. Ranitidin 2x1 amp iv- Inj. Tetagam 1 amp im- Inj. Ceftriaxon 2x1gram

iv

Mr. RT, 17 y.o. male •Multiple vulnus laseratum at regio genu dextra

- IVFD RL 20 tpm- Wound toilet- Hecting + dressing- Inj. KTC 3% 3x1 amp iv- Inj. Ranitidin 2x1 amp iv- Inj. Tetagam 1 amp im

Mr. YS, 20 y.o male •Vulnus laseratum at regio cruris dextra•Vulnus ekskoriatum at regio labialis

- Wound toilet- Hecting + dressing- KTC 3%1 amp iv- Tetagam 1 amp im

Mr. YU 40 y.o. male •Vulnus laseratum at regio tarsal pedis et cruris dextra•Vulnus ekskoriatum at regio dorsum manus dextra

- Wound toilet- Hecting + dressing- KTC 3%1 amp iv- Ranitidin 1 amp iv- Tetagam 1 amp im

• Name : Mr. WM• Age : 19 years old• Sex : Male• Address : Oesapa

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IDENTITYIDENTITY

• Chief Complaint : Stab wound on the abdomen

• Present History of Disease: Patient came to the ER because of the stab wound on the abdomen about 15 minutes before. The patient try to suicide by stab his stomach with knife. He feel pain on all area of abdomen, especially on the wound. Short of breath (+) bleeding (+) minimal, cramps (-), swelling (-), fever (-), nausea (-), vomit (-).

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ANAMNESISANAMNESIS

• A : clear• B : RR 44 x/m

– Inspeksi : mass (-), sikatriks (-), simetrical chest movement

– Palpation : Vocal fremitus D = S, crepitation (-)– Percusion : Sonor + +– Auscultation : Veshicular + +, Ronchi - -, Wheezing - -Assesment : takipnea ec abdominal painPlanning therapy : Inj. KTC 3% 1 amp ivEvaluasi : RR : 30 x/mnt

• C : BP 120/70 mmHg, Pulse 72 x/m• D : Alert• E : Vulnus ictum at regio epigastrium 2 x 1

cm, deep : 4 cmwww.themegallery.com Company Logo

PRIMARY SURVEYPRIMARY SURVEY

• GCS : E4V5 M6• Eye : anemic -/-, light reflex +/+,

icteric -/-• Ear : Normal• Nose : Normal• Throat : Normal

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SECONDARY SURVEYSECONDARY SURVEY

THORAX• Inspection : chest development

simetrics, abdominothoracal

• Palpation : vocal fremitus R=D

• Percusion : sonor (+/+)• Auscultation : vesicular (+/+),

ronchi (-/-), wheezing(-/-)


ABDOMEN• Inspection : distended (-),

mass (-), scar (-), vulnus ictum at regio epigastrium

2 x 1 x 4 cm• Auscultation : peristaltics (N),

metallic sound (-)

• Palpation : tenderness pain (+) , mass (-)

• Percussion : timpanic sound (+)www.themegallery.com Company Logo

vulnus ictum at regio epigastrium 2 x 1 x 4 cm

EXTREMITY

–LookNormal–FeelNormal–Move•ROM : Normal


• Vulnus ictum at regio epigastrium• Susp. Internal bleeding ec abdominal stab wound


ASSESSMENTASSESSMENT

- IVFD RL 20 dpm- Wound toilet- Hecting + dressing- Ketorolac 3% 1 amp iv- ATS 1500 IU im- Ceftriaxone 2 x 1 gram iv (ST)- Planning : laparatomi eksplorasi


THERAPYTHERAPY

MR 26 Juli Suicide

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