Patient List

No Identity Admission to ER Diagnosis Planning

Mr. Maulana/ 23 y.o/ May 27th 2019 at Vulnus laceratum ar palpebrae Treatmen from ER :
1-42-93-74 07.30 PM sinistra et dextra • Wound Toilet
• Primary suture (patient
decline)
• Observation 6 hours
• Po antibiotic
• Po analgetic
• Patient out by permission
 Mr. Maulana/ 23 y.o/ 1-42-93-74/
Admitted May 27th 2019 at 07.30 PM

Chief Complain : headache

History taking:
• patients present with complaints of pain in the head
after experiencing 30 minutes before entering the
hospital. single patient collision when riding a motorbike
with a speed of 50 km / h in a drunk state. patients do
not use helmets. the patient claimed to drink 2 bottles
of alcohol. the patient was found by the emergency
team to fall on the ground drunk. Nose bleeding (+)
nausea and vomiting (-), blurred vision (-), decreased
hearing (-), seizures (-), headaches (+)
• History of past Ilness: HT (-) DM (-)
 Primary Survey
• Airway :
• Airway clear (+) Snoring (-), gurgling (-) C-Spine control (-)
• Breathing :
• Lesion (-), symmetrical chest movement, tracheal deviation (-), jugular vein
distension (-), symmetrical VBS, RR : 18x/minute. SpO2 99% with O2 4 lpm
• Circulation :
• HR : 90x/minute (regular, strong pulse), BP : 130/80 mmHg, active bleeding (-)
• Disability :
• GCS E4V5M6, pupils equal 3mm/3 mm, direct light reflex (+/+), lateralization (-)
 Secondary Survey

• A:-
• M : analgetic
•P:-
• L : 07.00 pm
• E : fly over, banjarmasin
 • Eye : Sclera icteric (-/-), pale conjungtiva (-/-), pupil equal 3 mm|3 mm, hematoma
palpebral (-/-), Subconjungtiva bleeding (-/-) VL (+) ar palpebrae sx/dx
Head • Nose : bloody rhinorrhoea (+)
• Ear : ottorhea (-/-)
• Swelling a/r neck (-)

• I : symetric respiratory movement, retraction (-), bruise (-)

Chest • P : sonor at all lung fields
• A : symmetric VBS, rhonchi (-), wheezing (-)

• I : distension (-), lesion (-), hematoma (-)

• A : bowel sound (+) 8x/minute
Abdomen • P : soft, defense muscular (-) tenderness (-), H/L not palpable
• P : tympani at all region

• warm extremities (+), edema (-), paresis (-), pelvic stable

Extremities / • bloody discharge (-), hematoma penis (-)
Genitalia / Back • Back : vulnus (-), hematoma (-)
Local State
• I: Swelling (+) ar palpebrae sin,
Redness(-), haematom (+)
palpebrae sin, Vulnus
laceratum(+) ar palpebrae sx size
3 cm, ar palpebrae dx 3 cm and
2 cm
• P: Tenderness (+) crepitation (-)
Xray skull ap/lat
 Working Diagnosis

Vulnus laceratum ar palpebrae sinistra et dextra

 Management

Treatmen from ER :
• Wound Toilet
• Primary suture (patient decline)
• Observation 6 hours
• Po cefadroxyl 2x500mg
• Po mefenamic ac 3x500mg
• Patient out by permission