Duty Report

Sharifah Khalidah Syed Khalid

Nur Aisyah Amirah
Annisa Ayu Rahmawati
Nazza Rizky Ramdhagama
 Dokter Jaga Pasien
dr. Sandy Trauma = 2 pasien
dr. Rizky Non-Trauma = 0 pasien
Rawat inap = 2 pasien

Nama Usia Diagnosis

M 11 years old Subdural Hematome and Basilar
Skull Fracture
Mrs. N 19 years old Vulnus schlopetorum at lateral of right
femur
1 case
st
Identity & History

Name M Past Medical History:

Sex Male (-)
Age 11 y/o

Family History:
(-)
Other complaints:
Chief complaint:
 Active bleeding on his left ear
Pain on his nose, ear and head
and head
 Nausea and vomitus
 History of Present Illness

Patient presented with chief complain pain on his nose, ear and head
since 2 hour before entering hospital. Patient claimed that he got injured
when he was playing on the railroad tracks. Patient didn’thas any difficulty
moving his neck, no fever, no diploplia, no blurry vision. He had nausea
and vomitus. He had projectile vomits twice right after being hit by the
train. There is an abrasion wound on his stomach. Patient said there’s
active bleeding on his left ear and head. The bleeding has been controlled
by firm pressure with sterile cotton pad and already hected in Suka Mulya
Hospital. After the bleeding has been controlled, the patient go to Koja
General Hospital due to lack of instruments.
 MECHANISM OF TRAUMA
 Patient claimed that he got injured when he was playing on the
railroad tracks. He was hit and thud by the train.
 Loss of conciousness post trauma (-), nausea and vomitus (+)
 Past medical history: hypertension (-), dm (-), asthma (-),
congenital/acquired heart disease (-), past allergy history (-).
 Primary Survey
Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), BP: 110/80, HR: 92 x/mins, Temp: 37.0 C, CRT <2 sec
Disability :
GCS (E4M6V5) = 15
Secondary Survey

●Head : Bleeding (+), tenderness (+), crepitation (+), hected wound in occipital
sinistra and frontal region
●Eyes : Pupil reactive 3mm ODS, Isokor 3mm/3mm, CA (+/+), SI (-/-),
edema palpebra (+/-)
●Nose : bleeding (-), hected wound (+)
●Ear : Blood otorhea (+), hected wound (+)
●Mouth : Mucosa redness, cyanosis (-),
●Neck : Enlargement of lymph nodes (-)
Thorax Abdomen
Inspection : symmetric chest expantion,  Inspection: flat, masses (-),
effortless respiration, retraction (-), no abrasion wound on the right
scar. region (+)

Palpation: tenderness (-), normal vocal  Auscultation: bowel sound

fremitus, masses (-) 6x/min.
 Palpation: tenderness (-), defans
Percusion: sonor throughout the
muskular (-)
pulmonary area
 Percution: tympanic throughout
Auscultation: Vesiculer sound, Rh (-/-), the abdominal area
Wh (-/-). Heart sound I and II regular,
Murmur (-), Gallop (-).
 Extremities: CRT <2, edema (-),
2 case
nd
Identity & History

Name Mrs. N Past Medical History:

Sex Female (-)
Age 19 y/o

Family History:
(-)
Chief complaint: Other complaints:
Pain at thigh after accidentaly Difficulty in moving right leg due to
being shot pain
History of Present Illness
20:15 pm
19:45 pm
IGD
(before
RSUD
admitted)
IGD Koja

Patient was immediately

brought to RSUD Koja
Patient was doing house Patient complaints
chores when the gun fell pain at wound site
and accidentally fired
her right side of right
thigh

Biomechanism of Trauma
 Primary Survey
Airway :
Airway obstruction (clear)
Breathing :
Spontaneous breathing (+), retraction (-), RR: 20 x/mins
Circulation :
Pulse (+, regular), cold extremities, BP: 120/90, HR: 112 x/mins, Temp: 36.0 C, CRT <2 sec
Disability :
GCS (E4M6V5) = 15
Secondary Survey

●Head : Bleeding (-), swelling (-), tenderness (-), hematoma (-)

●Eyes : Eyebrow (-), Isokor 3mm/3mm, CA (-/-), SI (-/-)
●Nose : hair nose (-), Bleeding (-)
●Ear : Normotia, bleeding (-)
●Mouth : Mucosa redness, cyanosis (-),
●Neck : Enlargement of LN (-)
Thorax :
• Inspection : Symmetrical
• Palpation : Vocal fremitus & tactile symmetrical
• Percussion : resonance in both lungs
• Auscultation : Vesicular, Rh -/-, Wh -/-; Heart sound I-II normal

Abdomen :
• Inspection : Flat, mass (-),
• Auscultation : Peristaltic sound (+), normoperistaltic
• Palpation : Soft & non tender, distention (-)
• Percussion : Tymphany
 Local state of right femur
• Look: swelling, vulnus
schlopetorum at lateral right femur
with circular shape, regular edge,
base of wound muscle layer, around
the wound: vulnus excoriatum ±2
cm x ±0.2 cm
• Feel: pain on palpitation
• Move: extension, flexion, internal
rotation, external rotation,
abduction, adduction of hip limited
due to pain. Normal extension,
flexion of knee.
Diagnosis and problem

Problems:
Working diagnosis:
• Gunshot wound
Vulnus schlopetorum at lateral of • Pain
right femur • Inflammation
• Infection
• Vasular injury
Management

SURGERY NON SURGERY

Consult a general surgeon Pharmacology

Ceftriaxone 2x1g
Ketorolac 3x30mg

Non-pharmacology
Bed rest
Wound care