AR IGD 23 November 2023

UGD 23 NOVEMBER 2023
Initial Gender Age Medical Diagnosis Treatment

record
• WT + HT
Open wound of lip • inj tetagam
AA M 24 y.o 751575 and oral cavity Cefixime 2x200 mg outpatient
•
• Paracetamol 3x500mg
Vulnus Excoriatum • WT
IKS M 51 y.o 708157 Regio Cruris • Cefixime 2x200 mg outpatient
Sinistra • Paracetamol 3x500mg
NKSDA F 12 y.o 651605 Vulnus ictum regio • Wound Toilet outpatient
plantar pedis • Wound exploration
sinistra • Tetagam injection IM
• paracetamol 3x500mg
• cefixime 2x100mg
Open wound of lip and Oral cavity
Patient Identity
Name : AA
Gender : Male
Age : 24 Years
Address : taman, gianyar
No.RM : 751575
PRIMARY SURVEY
A: Clear
B: Spontaneus, RR 22x/menit, SpO2 99% on RA
C: Stable, BP 120/70 mmHg, HR 90x/menit, CRT < 2s
D: GCS E4M6V5, round and equal pupils of 2mm/2mm, RP +/+, no signs of

lateralization (-)
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.
Mechanism of Injury (MOI):

The patient was hit by a cement mixer hose while working on the construction site.
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 and has a
complete vaccination history.
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 (-).
Personal and Social History:
The patient is a construction worker involved in moderate to heavy physical activities. The patient denies 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: Warm (++/++), cyanosis (--/--), edema (--/--), Capillary Refill Time (CRT) < 2 seconds.
Status Lokalis
Local Status (Oral Regio)
Look:
• Open wound in oral cavity (+) measuring 1 cm x 1 cm x 1
cm with tissue base, active bleeding (+), edema (-).
• A scratch wound in preoral region (+) measuring 1 cm x 1
cm x 1 cm with tissue base, active bleeding (-), edema (-).
Feel:
• Tenderness upon palpation (+), no crepitus, no deformity,
sensory touch and pain (+).
Move:
• Temporomandibular joint : ROM active (+)
• Diagnosis TATALAKSANA
• Wound Treatment + primary
Open wound of lip and Oral
cavity hecting
• inj tetagam
• Cefixime 2x200 mg
• KIE
Vulnus Excoriatum Regio Cruris Sinistra
Patient Identity
Name : IKS
Gender : Male
Age : 51 Years
Address : Sema Bitra, Gianyar
No.RM : 708157
PRIMARY SURVEY
A: Clear

lateralization (-)
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 (-).
Personal and Social History:

The patient is a private employee with mild-moderate physical activity. The patient denies any
history of alcohol consumption and smoking.
SECONDARY SURVEY
palpation (-).
- Extremities: according to localist status
Localist Status
Local Status (Regio Cruris Sinistra)
Look:
• blisters on the left calf (+), active bleeding (-), edema (-),
cyanosis (--/--)
Feel:
• Warm (+), Tenderness upon palpation (+), no crepitus, no
deformity, sensory touch and pain (+), CRT <2s
Move:
• Knee joint : Active ROM (+)
• Ankle joint : Active ROM (+)
• Diagnosis TATALAKSANA
Vulnus Excoriatum Regio • Wound Treatment
Cruris Sinistra • Cefixime 2x200 mg
Vulnus Ictum Regio Plantar Pedis Sinistra
Patient Identity
Name : NKSDA
Gender : Female
Age : 12 Years
Address : Bedulu, Gianyar
No.RM : 651605
PRIMARY SURVEY
A: Clear

lateralization (-)
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.
Family history of illness:
There are no similar complaints in the patient's family. Family history of chronic diseases such as
DM (-), hypertension (-), heart disease (-).
Personal and social history:
The patient is a 6th grade student with light-moderate activity. The patient denied any history of
alcohol consumption and smoking.
SECONDARY SURVEY
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 :
Ankle Joint : Limited ROM pain (-)

MTP joint : Limited ROM pain (-)
• Diagnosis Treatment
• Wound toilet
Vulnus Ictum Regio Plantar
• Wound exploration
Pedis Sinistra
• Inj. IM Tetagam
• Cefixime 2x1mg
THANK YOU

AR IGD 23 November 2023

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AR IGD 23 November 2023

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UGD 23 NOVEMBER 2023

Initial Gender Age Medical Diagnosis Treatment

Address : taman, gianyar

B: Spontaneus, RR 22x/menit, SpO2 99% on RA

C: Stable, BP 120/70 mmHg, HR 90x/menit, CRT < 2s

D: GCS E4M6V5, round and equal pupils of 2mm/2mm, RP +/+, no signs of

Mechanism of Injury (MOI):

Address : Sema Bitra, Gianyar

B: Spontaneus, RR 18x/menit, SpO2 98% on RA

C: Stable, BP 110/80 mmHg, HR 85x/menit, CRT < 2s

D: GCS E4M6V5, round and equal pupils of 2mm/2mm, RP +/+, no signs of

Personal and Social History:

Address : Bedulu, Gianyar

B: Spontaneus, RR 22x/menit, SpO2 99% on RA

C: Stable, BP 120/70 mmHg, HR 90x/menit, CRT < 2s

D: GCS E4M6V5, round and equal pupils of 2mm/2mm, RP +/+, no signs of

Family history of illness:

Personal and social history:

Ankle Joint : Limited ROM pain (-)

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