DM/M/28yo

66.87.79
Chief Complain : Lacerated Wound o/t (R) lower arm.

I has been suffered by the patient since 1 hours

before admitted to Adam Malik Hospital. The
forearm was lacerated by a sparkling glass when
patient was working at home. Bleeding (-), pain (+).
Patient still capable to move his leg normally.
Primary Survey :
A : Clear
B : Spontan, RR : 22 x/min
C : warm acral, HR : 92 x /min,
BP : 110/70mmHg
D : GCS 15
E : undressed, logroll
 AMPLE
• A : no history of allergy
• M : no history of previous medication
• P : no history of past illness
• L : last meal 3 hours before accident
• E : Home
Secondary survey

Head : No abnormality found

Neck : No abnormality found
Chest : No abnormality found
Abdomen : No abnormality found
Genitalia : male, no abnormality
Extremities : In localized state
Localized Status :
Superior extremity :
(R) Lower Arm:
Lacerated wound o/t ( R )
fore arm, size 7x 2x1 cm,
reguler edge,subcutis
based, minimal
contamination, active
bleeding (-).
Working Diagnose :
Lacerated wound o/t (R) lower arm
• Treatment at the ER :
– Inj. ATS
– Inj. Antibiotic
– Inj. Analgesic
– Wound toilet + Primary suture