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  • TN Fahrudin Vulnus Excoriatum

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    monyet65
    166 vizualizări10 pagini
    1. Mr. Fahrudin, a 23-year-old male, was admitted to the ER on May 12th, 2019 at 9:15 am following a single-vehicle accident where his leg was caught in an engine while avoiding a hole. 2. Upon examination, he was found to have multiple excoriated wounds on his right knee, lower leg, and foot. His vital signs were stable. 3. He was diagnosed with multiple excoriated wounds on his right knee, lower leg, and foot. His treatment plan included wound cleaning, oral medications, topical antibiotics, and discharge with permission.

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    Tn Fahrudin Vulnus Excoriatum

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    1. Mr. Fahrudin, a 23-year-old male, was admitted to the ER on May 12th, 2019 at 9:15 am following a single-vehicle accident where his leg was caught in an engine while avoiding a hole. 2. Upon examination, he was found to have multiple excoriated wounds on his right knee, lower leg, and foot. His vital signs were stable. 3. He was diagnosed with multiple excoriated wounds on his right knee, lower leg, and foot. His treatment plan included wound cleaning, oral medications, topical antibiotics, and discharge with permission.

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    © All Rights Reserved
    Descărcați ca PPTX, PDF, TXT sau citiți online pe Scribd
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    166 vizualizări10 pagini

    TN Fahrudin Vulnus Excoriatum

    Încărcat de

    monyet65
    1. Mr. Fahrudin, a 23-year-old male, was admitted to the ER on May 12th, 2019 at 9:15 am following a single-vehicle accident where his leg was caught in an engine while avoiding a hole. 2. Upon examination, he was found to have multiple excoriated wounds on his right knee, lower leg, and foot. His vital signs were stable. 3. He was diagnosed with multiple excoriated wounds on his right knee, lower leg, and foot. His treatment plan included wound cleaning, oral medications, topical antibiotics, and discharge with permission.

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    din 10

    Patient List

    No Identity Admission to ER Diagnosis Planning

    2. Mr. Fahrudin/ 23 12th May 2019 at Multiple Vulnus Excoriatum at Treatment at ER


    y.o/1428104/ 09.15 am regio right Genu, right Cruris, • Wound Toilet
    and right Pedis • Po. Mefenamic Acid
    3x500mg
    • Po. Ranitidin 2 x 150mg
    • Gentamicin zalf
    • Patient out by permission
    2. Mr. Fahrudin/ 23 y.o/1428104/
    admitted 12th May 2019 at 09.15 am

    Chief Complain: Pain In foot and knee


    History taking
    Patients present with complaints of foot and knee injuries, this is felt by the
    patient since 1 hour before entering the hospital, after the patient has had an
    accident in Trikora banjarbaru, a single accident occurs when the patient is
    avoiding a hole and the patient falls to the left and the patient's leg is caught
    engine, the patient uses a helmet. The patient can still walk, the right toes can
    still be in motion, foot tingling (-). There is no decrease in consciousness (-)
    nausea and vomiting (- / -) headache (-), seizures (-), double control (-)
    History of Past Illness : (-)
    History of Family Illness : (-)
    Primary Survey
    • Airway :
    – Clear with C-Spine control
    • Breathing :
    – Lesion (-), symmetrical chest movement, tracheal deviation (-), jugular vein
    distension (-), RR : 18x/minute (regular), Vesicular breath sound both side. SpO2 :
    98% without O2.
    • Circulation :
    – Pulse : 87x/minute (strong, regular), BP : 110/70 mmHg, active bleeding (-).
    • Disability :
    – GCS E4V5M6, pupils equal 3 mm/3 mm, direct light reflex (+/+), indirect light
    reflex (+/+), lateralization (-/-), BO (-/-), BR (-/-), BS (-/-), BH (-/-).
    Secondary Survey
    • Allergy : (-)
    • Medication : (-)
    • Past Illness: (-)
    • Last Meal : 03.00 am
    • Environment : Trikora Banjarbaru
    • Eye : sclera icteric (-), pale conjungtiva (-/-), pupil equal (3mm/3mm), lights reflex (+/
    +), subconjuntiva bleeding (-|-)
    Head & Neck • bloody rinorrhea (-/-), bloody otorrhea (-/-)
    • enlargement lymph node (-), lesion (-), edema (-|-)

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


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

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


    • A : bowel sound (+) 6x/minutes
    Abdomen • P : soft, defense muscular (-) tenderness hard to evaluate, liver and spleen not
    palpable
    • P : tympani at all region

    Extremities • Cold extremities (+), edema (-|-), lateralization (-/-)


    Clinical Picture
    Clinical Picture
    Diagnosis
    • Multiple Vulnus Excoriatum at regio right Genu, right Cruris,
    and right Pedis
    Management
    Treatment in ER :
    • Wound Toilet
    • Po. Mefenamic Acid 3x500mg
    • Po. Ranitidin 2 x 150mg
    • Gentamicin zalf
    • Patient out by permission

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