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    Morpot TGL 19 November

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    Charles Hasudungan Siregar
    Mr. A, a 34-year-old man, was in a motorcycle accident and suffered a bruise on his posterior lip region. During the primary survey, his airway was clear and breathing was normal. In the secondary survey, examination found a vulnus eksoriasi and pain on his right forehead. The diagnosis was contusion and laceration wound. The treatment plan included wound cleaning, observation, analgesics, and antibiotics but no hospitalization.

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    Morpot TGL 19 November

    Uploaded by

    Charles Hasudungan Siregar
    39 views27 pages
    Mr. A, a 34-year-old man, was in a motorcycle accident and suffered a bruise on his posterior lip region. During the primary survey, his airway was clear and breathing was normal. In the secondary survey, examination found a vulnus eksoriasi and pain on his right forehead. The diagnosis was contusion and laceration wound. The treatment plan included wound cleaning, observation, analgesics, and antibiotics but no hospitalization.

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    Morpot Tgl 19 November

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    Mr. A, a 34-year-old man, was in a motorcycle accident and suffered a bruise on his posterior lip region. During the primary survey, his airway was clear and breathing was normal. In the secondary survey, examination found a vulnus eksoriasi and pain on his right forehead. The diagnosis was contusion and laceration wound. The treatment plan included wound cleaning, observation, analgesics, and antibiotics but no hospitalization.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    39 views27 pages

    Morpot TGL 19 November

    Uploaded by

    Charles Hasudungan Siregar
    Mr. A, a 34-year-old man, was in a motorcycle accident and suffered a bruise on his posterior lip region. During the primary survey, his airway was clear and breathing was normal. In the secondary survey, examination found a vulnus eksoriasi and pain on his right forehead. The diagnosis was contusion and laceration wound. The treatment plan included wound cleaning, observation, analgesics, and antibiotics but no hospitalization.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 27

    Mr A ( 34 YO)

    Mekanisme of the trauma :motorcycle crash


    Injury of target organ : regio labialis posterior
    Symptoms and signs : pain on the bruise
    Transport : by car

    PRIMARY SURVEY
    Airway : clear ( no snoring, no gargling, no stridor)
    conclusion : clear.

    Breathing :
    Inspeksi : bruise -, chest wall movement symmetrical, RR
    20x/min, hematom
    Palpasi : crepitation pain (-)
    Perkusi : sonor right = left
    Auskultasi : basic breath sound vesikuler


    HISTORY OF ILNESS
    30 minute before enter to hospital
    patient have an motorcycle accident.
    when patients are riding motorcycles fast
    and heavy rain, and the patient's motor slip
    hit car in front. patient could not avoid the
    sudden stop. patients eventually fell and
    bloody lip patients because a tear. no
    head injury, no collision chest, no fainting,
    no amnesia, no vomiting, no nausea.
    PRIMARY SURVEY
    C : warm extremities, Pulse = 82
    x/mnt , BP: 120/80mmHg, Temp=
    36
    0
    C, capillary refill <2
    Conclusion : no sign of shock



    PRIMARY SURVEY
    Disability
    GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm,
    centered, direct light reflex/indirect light reflex
    +/+

    Exposure
    no life-threatening injury

    Secondary Survey
    Chief complaint : pain on the bruise
    Additional complaint : weakness

    SECONDARY SURVEY

    HEAD TO TOE

    regio frontalis dextra
    Look : vulnus eksoriasi(+), jejas (+), edema (-)
    Feel : pain (+) , crepitation (-)
    Move : dorso flexi +, anteflexi +, abduksi +, adduksi +



    SECONDARY SURVEY
    Eyes : Pupil circular, isochoric
    3mm/3mm, conjuntiva
    anemis -/-, sclera icteric -/-
    Ear : secret -/-, blood -
    Nose : secret -/-, blood -
    Neck : bruise - , hematom -



    Thorax :
    Insp : movement of chest wall
    symmetrical
    Pal : vocal fremitus right = left
    Per : sonor right = left
    Aus : vesiculer, rhonki -/-, wheezing -
    /-

    Abdomen :
    Ins : flat, bruise (-), mass (-)
    Aus : bowel sound (+) 4times/minute
    Pal : tenderness (-)
    Per : tympani, percussion pain (-)
    Ekstremitas :
    warm extremities, cap. refill < 2, edema (-)
    DIAGNOSIS

    CKR + Vulnus laceratum
    TREATMENT
    Patient not hospitalized
    Wound toilet
    Hecting
    Observasi

    Medication
    Analgetic
    Antibiotic
    3. Mr H ( 21 YO)
    Mekanisme of the trauma : accident a suicide
    attempt
    Injury of target organ : Regio antebrachii
    sinistra
    Symptoms and signs : pain on the bruise
    Transport : by motorcycle

    HISTORY
    1 hour before to hospital, the patient
    had an accident a suicide attempt for
    arguing with his girlfriend, patients slashing
    his left hand with a razor blade to cause
    open sores and bleeding. before the
    patient was taken to the clinic, but only
    wound bandaged it. eventually the patient
    to the hospital uki.
    PRIMARY SURVEY
    Airway : clear ( no snoring, no gargling, no stridor)
    conclusion : clear.
    Breathing :
    Inspeksi : bruise -, chest wall movement
    symmetrical, RR 24x/min, hematom
    Palpasi : crepitation
    Perkusi : sonor right = left
    Auskultasi : basic breath sound vesikuler


    PRIMARY SURVEY
    Circulation : warm extremities, Pulse
    = 82 x/mnt , BP: 140/100mmHg,
    Temp= 36
    0
    C, Respiration Rate :
    24x/menit, capillary refill <2
    Conclusion : no sign of shock



    PRIMARY SURVEY
    Disability
    GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm,
    centered, direct light reflex/indirect light
    reflex +/+

    Exposure

    no life-threatening injury
    Secondary Survey
    Chief complaint : pain and
    bleeding on the bruise
    Additional complaint : weakness

    Status localis
    1. Regio antebrachii
    Look : jejas (+), bruise (+), bleeding (+),
    edema (-)
    Feel : pain in wound
    Move : flexi +, anteflexi +, abduksi +, adduksi +
    Eyes : Papil circular, isochoric
    3mm/3mm,conjuntiva
    anemis -/-, sclera icteric -/-
    Ear : secret -/-, blood -
    Nose : secret -/-, blood -
    Neck : bruise - , hematom -



    Thorax :
    Insp : movement of chest wall
    symmetrical
    Pal : vocal fremitus right = left
    Per : sonor right = left
    Aus : vesiculer, rhonki -/-, wheezing -
    /-

    Abdomen :
    Ins : flat, bruise (-), mass (-)
    Aus : bowel sound (+) 4 times/minute
    Pal : tenderness (-)
    Per : tympani, percussion pain (-)
    Ekstremitas :
    warm extremities, cap. refill < 2, edema (-)
    DIAGNOSIS

    Vulnus Lacseratum e.c
    sharps
    TREATMENT
    Patient pro hospitalized
    Wound toilet
    Hecting

    Medicamentosa
    - Analgetic
    - Antibiotic

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