Mr A ( 34 YO)

Mekanisme of the trauma :motorcycle crash

Injury of target organ : regio labialis posterior
Symptoms and signs : pain on the bruise
Transport : by car

PRIMARY SURVEY
Airway : clear ( no snoring, no gargling, no stridor)
conclusion : clear.

Breathing :
Inspeksi : bruise -, chest wall movement symmetrical, RR
20x/min, hematom
Palpasi : crepitation pain (-)
Perkusi : sonor right = left
Auskultasi : basic breath sound vesikuler


HISTORY OF ILNESS
30 minute before enter to hospital
patient have an motorcycle accident.
when patients are riding motorcycles fast
and heavy rain, and the patient's motor slip
hit car in front. patient could not avoid the
sudden stop. patients eventually fell and
bloody lip patients because a tear. no
head injury, no collision chest, no fainting,
no amnesia, no vomiting, no nausea.
PRIMARY SURVEY
C : warm extremities, Pulse = 82
x/mnt , BP: 120/80mmHg, Temp=
36
0
C, capillary refill <2
Conclusion : no sign of shock



PRIMARY SURVEY
Disability
GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm,
centered, direct light reflex/indirect light reflex
+/+

Exposure
no life-threatening injury

Secondary Survey
Chief complaint : pain on the bruise
Additional complaint : weakness

SECONDARY SURVEY

HEAD TO TOE

regio frontalis dextra
Look : vulnus eksoriasi(+), jejas (+), edema (-)
Feel : pain (+) , crepitation (-)
Move : dorso flexi +, anteflexi +, abduksi +, adduksi +



SECONDARY SURVEY
Eyes : Pupil circular, isochoric
3mm/3mm, conjuntiva
anemis -/-, sclera icteric -/-
Ear : secret -/-, blood -
Nose : secret -/-, blood -
Neck : bruise - , hematom -



Thorax :
Insp : movement of chest wall
symmetrical
Pal : vocal fremitus right = left
Per : sonor right = left
Aus : vesiculer, rhonki -/-, wheezing -
/-

Abdomen :
Ins : flat, bruise (-), mass (-)
Aus : bowel sound (+) 4times/minute
Pal : tenderness (-)
Per : tympani, percussion pain (-)
Ekstremitas :
warm extremities, cap. refill < 2, edema (-)
DIAGNOSIS

CKR + Vulnus laceratum
TREATMENT
Patient not hospitalized
Wound toilet
Hecting
Observasi

Medication
Analgetic
Antibiotic
3. Mr H ( 21 YO)
Mekanisme of the trauma : accident a suicide
attempt
Injury of target organ : Regio antebrachii
sinistra
Symptoms and signs : pain on the bruise
Transport : by motorcycle

HISTORY
1 hour before to hospital, the patient
had an accident a suicide attempt for
arguing with his girlfriend, patients slashing
his left hand with a razor blade to cause
open sores and bleeding. before the
patient was taken to the clinic, but only
wound bandaged it. eventually the patient
to the hospital uki.
PRIMARY SURVEY
Airway : clear ( no snoring, no gargling, no stridor)
conclusion : clear.
Breathing :
Inspeksi : bruise -, chest wall movement
symmetrical, RR 24x/min, hematom
Palpasi : crepitation
Perkusi : sonor right = left
Auskultasi : basic breath sound vesikuler


PRIMARY SURVEY
Circulation : warm extremities, Pulse
= 82 x/mnt , BP: 140/100mmHg,
Temp= 36
0
C, Respiration Rate :
24x/menit, capillary refill <2
Conclusion : no sign of shock



PRIMARY SURVEY
Disability
GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm,
centered, direct light reflex/indirect light
reflex +/+

Exposure

no life-threatening injury
Secondary Survey
Chief complaint : pain and
bleeding on the bruise
Additional complaint : weakness

Status localis
1. Regio antebrachii
Look : jejas (+), bruise (+), bleeding (+),
edema (-)
Feel : pain in wound
Move : flexi +, anteflexi +, abduksi +, adduksi +
Eyes : Papil circular, isochoric
3mm/3mm,conjuntiva
anemis -/-, sclera icteric -/-
Ear : secret -/-, blood -
Nose : secret -/-, blood -
Neck : bruise - , hematom -



Thorax :
Insp : movement of chest wall
symmetrical
Pal : vocal fremitus right = left
Per : sonor right = left
Aus : vesiculer, rhonki -/-, wheezing -
/-

Abdomen :
Ins : flat, bruise (-), mass (-)
Aus : bowel sound (+) 4 times/minute
Pal : tenderness (-)
Per : tympani, percussion pain (-)
Ekstremitas :
warm extremities, cap. refill < 2, edema (-)
DIAGNOSIS

Vulnus Lacseratum e.c
sharps
TREATMENT
Patient pro hospitalized
Wound toilet
Hecting

Medicamentosa
- Analgetic
- Antibiotic