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    M: Beaten by People I: Left Eye S: Pain, Hematoma, Active Bleeding (+) T

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    Ferdy Erawan
    The document describes a medical examination of a patient who was beaten after trying to steal a motorcycle. The patient has an active bleeding wound above their left eye and bruising on their right eye. The examination notes vital signs, examination of bodily systems, and treatment including cleaning and stitching the wound.

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    M: Beaten by People I: Left Eye S: Pain, Hematoma, Active Bleeding (+) T

    Uploaded by

    Ferdy Erawan
    18 views10 pages
    The document describes a medical examination of a patient who was beaten after trying to steal a motorcycle. The patient has an active bleeding wound above their left eye and bruising on their right eye. The examination notes vital signs, examination of bodily systems, and treatment including cleaning and stitching the wound.

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    asd

    Original Title

    morpot1

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    The document describes a medical examination of a patient who was beaten after trying to steal a motorcycle. The patient has an active bleeding wound above their left eye and bruising on their right eye. The examination notes vital signs, examination of bodily systems, and treatment including cleaning and stitching the wound.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    18 views10 pages

    M: Beaten by People I: Left Eye S: Pain, Hematoma, Active Bleeding (+) T

    Uploaded by

    Ferdy Erawan
    The document describes a medical examination of a patient who was beaten after trying to steal a motorcycle. The patient has an active bleeding wound above their left eye and bruising on their right eye. The examination notes vital signs, examination of bodily systems, and treatment including cleaning and stitching the wound.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 10

    M : beaten by people

    I : left eye
    S : Pain, hematoma, active bleeding (+)
    T : -
    Airway : Clear ( snoring -, gurgling -,
    stridor - )
    Breathing :
    Insp : bruise (-), chest wall movement
    symmetrical right and left, RR 18 x/
    min, hematoma (-)
    Pal : crepitation sub cutis (-)
    Per : sonor right = left
    Aus : Basic breath sound vesicular
    right and left


    C = warm extremities, Pulse = 84bpm, BP
    110/70 mmHg, capillary refill time <2
    D = GCS E4M6V5, pupil isocors 3mm/3mm,
    centered, direct light reflex/,indirect light
    reflex +/+
    E = there is no life threatening wound
    History of illness :
    Patient came to Pelabuhan Hospital with bleeding
    wound at his upper of left eye. He got beaten by
    people when he try to steal motorcycle.
    HEAD TO TOE
    Eyes : pupil isocors 3mm/3 mm, centered,
    direct light reflex/ indirect light reflex +/+, hematoma
    (+/+), bruise (+/+), active bleeding (+)
    Ear : Bruise (-), hematoma (-)
    Neck : Bruise (-), hematoma (-)
    Thorax :
    Insp : bruise (-), movement of chest wall symmetrical
    Pal : crepitation (-), tenderness (-)
    Per : sonor right = left
    Aus : Basic breath sound vesicular right and left



    SECONDARY SURVEY
    Abdomen :
    Ins : flat, bruise (-)
    Aus : bowel sound (+) 6x/min
    Pal : Supel, tenderness (-),
    muscular defense (-)
    Per : tympani
    Extremity:
    Warm extremities, cap. refill time < 2, edema (-)
    Left eye
    Ins :
    Laceration wound L : 4 cm, w : 1cm, deep : 1cm, bruise
    (+), active bleeding (+), hematoma (+)
    Pal :
    tenderness (+)

    Right Eye
    Ins : hematoma (+), bruise (+)
    Laceration wound with bruise and
    hematoma on left eye
    Bruise and hematoma on right eye
    Clean the wound
    Stitch the wound
    Give TT and tetagam injection
    AB and Analgesic

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