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AR IGD 23 November 2023
AR IGD 23 November 2023
Gender : Male
Age : 24 Years
No.RM : 751575
PRIMARY SURVEY
A: Clear
E: Temp 36,8 C
Anamnesis
Main Complaint: Wound on the oral cavity
Current Medical History:
A 24-year-old male came to the Emergency Department of Sanjiwani Hospital with a complaint
of an injury to the mouth area after being hit by a cement mixer hose. The incident occurred
while the patient was attempting to start the cement mixer at a construction site, where the
rotating hose spun too vigorously and struck the patient's mouth. There is no history of chest
trauma. The patient denies any loss of consciousness, projectile vomiting, or seizures
immediately after the incident.
Gender : Male
Age : 51 Years
No.RM : 708157
PRIMARY SURVEY
A: Clear
E: Temp 36,5 C
Anamnesis
Main Complaint: blisters on the left calf
Current Medical History:
A 51-year-old male patient came to Sanjiwani Hospital with a complaint of a blister on
his left calf due to a horse bite 15 minutes before admission. The complaint was obtained
when the patient invited his child to play by looking at the horse, the horse accidentally
bit the patient's left calf. There were no other accompanying complaints.
Mechanism of Injury (MOI):
The patient was taking his child to see a horse and the horse accidentally bit his calf.
Anamnesis
Past Medical History:
The patient has never had a similar complaint before. There is no history of chronic diseases such
as hypertension, diabetes mellitus, or blood clotting disorders. The patient denies any allergies.
Family Medical History:
There are no similar complaints in the patient's family. The family history does not include chronic
diseases such as diabetes (-), hypertension (-), or blood clotting disorders (-).
Gender : Female
Age : 12 Years
No.RM : 651605
PRIMARY SURVEY
A: Clear
E: Temp 36,8 C
Anamnesis
Chief Complaint: Wound on left foot
History of Present Illness:
The patient came in conscious with a complaint of a wound on the sole of the left foot 30
minutes before admission. The complaint was felt after the patient was punctured by a 5 cm nail
while sweeping. During the incident, the nail penetrated the patient's sandal. The patient had
cleaned the wound using water. The wound was accompanied by pain. The patient felt the
complaint continuously. Other complaints such as fever (-), tingling (-), movement disorder (-).
MOI:
The patient was punctured by a 5 cm nail on the sole of his left foot while sweeping his yard.
Anamnesis
Past medical history:
The patient has never had similar complaints. The patient has no history of hypertension and
diabetes militus. History of allergy in the patient is denied.
There are no similar complaints in the patient's family. Family history of chronic diseases such as
DM (-), hypertension (-), heart disease (-).
The patient is a 6th grade student with light-moderate activity. The patient denied any history of
alcohol consumption and smoking.
SECONDARY SURVEY
- Head: Normocephalic .
- Eyes: Conjunctiva pale (-/-), sclera icteric (-/-), pupil reflex (+/+).
- ENT (Ear, Nose, Throat): Appears calm, no ear discharge (-/-), no rhinorrhea (-/-).
- Neck: No visible injuries, no deformities.
- Chest: Symmetrical (+/+), no retractions (-/-).
- Abdomen: No visible injuries, no distension (-), bowel sounds (BS) normal, no tenderness upon
palpation (-).
- Extremities: according to localist status
Localist Statust
Localist Status (Regio plantar pedis sinistra)
Look: stab wound (+) size 0.1 cm x 0.1 cm x
0.1 cm, active bleeding (-), edema (-),
hyperemia (-).
Feel: tenderness (+), crepitation (-), deformity
(-), sensation of touch and pain (+)Move :