26 Juli 2013 Coass jaga: Rico Rotinggo Margareta J.

Sono

RESUME
Identity Mr. WM, 19 y.o. male Diagnose Vulnus ictum at regio epigastrium Susp. Internal bleeding ec abdominal stab wound Therapy IVFD RL 20 dpm Wound toilet Hecting + dressing Ketorolac 3% 1 amp iv ATS 1 amp im Ceftriaxone 2x1 gram iv Pro laparatomi exploration 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 IVFD RL 20 tpm Wound toilet Hecting + dressing Inj. KTC 3% 3x1 amp iv Inj. Ranitidin 2x1 amp iv Inj. Tetagam 1 amp im
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Mr. MT, 18 y.o. male

Vulnus laseratun at regio genu dextra Open fracture patellad extra Susp. Fractur femur dextra

Mr. RT, 17 y.o. male

Multiple vulnus laseratum at regio genu dextra May 9th 2013

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

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

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ANAMNESIS
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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 A : clear B : RR 44 x/m
Inspeksi Palpation Percusion Auscultation Assesment Planning therapy Evaluasi

PRIMARY SURVEY
: mass (-), sikatriks (-), simetrical chest movement : Vocal fremitus D = S, crepitation (-) : Sonor + + : Veshicular + +, Ronchi - -, Wheezing - : takipnea ec abdominal pain : Inj. KTC 3% 1 amp iv : 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 cm cm, deep : 4 cm
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SECONDARY SURVEY
GCS Eye Ear Nose Throat : E4V5 M6 : anemic -/-, light reflex +/+, icteric -/: Normal : Normal : Normal

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 Inspection : chest development simetrics, abdominothoracal Palpation : vocal fremitus R=D Percusion : sonor (+/+) Auscultation : vesicular (+/+), ronchi (-/-), wheezing(-/-)

THORAX

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 Inspection Auscultation Palpation Percussion

ABDOMEN

: distended (-), mass (-), scar (-), vulnus ictum at regio epigastrium 2 x 1 x 4 cm : peristaltics (N), metallic sound (-) : tenderness pain (+) , mass (-) : timpanic sound (+)

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vulnus ictum at regio epigastrium 2 x 1 x 4 cm

EXTREMITY
Look Normal Feel Normal Move ROM : Normal
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ASSESSMENT
Vulnus ictum at regio epigastrium Susp. Internal bleeding ec abdominal stab wound

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THERAPY
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
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