simple wound
Post on 14-Dec-2015
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No.Name : Mr. A Sex : male
Age : 18 years old No. Reg : 628051
Main complaint : Wound on the foot
Case : The condition had suffered for 1 hours before the patient taken to the hospital. There was no history loss of consciousness and no vomiting.
Mechanism of injury
: He was walking on the street without sandal, then accidentally his right foot punctured by a rusty nail.
Sustained injury : Right FootSymptom & sign : woundExamination : Physical examination
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
Primary SurveyPrimary Survey
A: Clear
B: RR : 22x/minutes, spontaneous, symmetric, thoraco abdominal type
C: BP : 120/80 mmHg, PR : 84x/minute, regular, adequate
D: GCS 15 (E4M6V5), pupil equal Ø 2,5 /2,5 mm, Light Reflex +/+
E: T (ax) : 36,5 oC
Secondary SurveySecondary Survey
Right Plantar region :I : Seen punctured wound size 1x0,5 cm. Edema (-)P : Crepitation (-)
WORKING DIAGNOSIS : - Vulnus ictum at right plantar region
MANAGEMENT : • Medicament• Proceed Wound Care• Patient discharge
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