07022014

Emergency Unit

Night Shift Report

February 7th, 2014

TRAUMA

1. E (25 Y.O.)• M: Fall from motorcycle

• I: Vulnus laseratum regio supra orbita

• S: -

• T: Patient rode to the hospital with friends with motorcycle

PRIMARY SURVEY

• Patient can talk coherently in a long sentence

• Patient came with his friends

PHYSICAL EXAMINATION

• Airway : Clear• Breathing :

Insp : symmetrical movement of chest wall, bruise (-), RR : 20x/mins

Pal : VF right = left, crepitation (-), pain on palpation (-) Per : sonor right = left, pain on percussion(-) Aus : vesicular basic breath sound, wh -/-, rh-/-

• C = Warm extremities, Pulse = 84 x/min , BP =130/70 mmHg, temperature = 36,5 °C,

capillary refill < 2” • D = GCS 15 – E4V5M6 , pupil isochoric 3 mm / 3

mm, direct light reflex/indirect light reflex +/+, lateralization (-)

• E = There’s no life threatening wound and bruise


1 hour before Patient came to the hospital he had motorcycle accident. Patient didn’t use helmet, motorcysle speed is 70 km/hour. Patient said he fall to the right side of motorcycle and his head get hit by trotoar. After the accident patient still concious. Naussea and vomitting denied.

History of illness

HEAD TO TOE

General ExaminationHead : Bruise (-), edema (-), tumor (-), wound (+) on

regio supra orbita sinistraEyes : Round shaped pupil, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect Light Reflex +/+, CA-/-, SI-/-

Neck : Bruise (-), hematoma (-), no palpable enlargement on regional lymph nodes

SECONDARY SURVEY

Thorax Insp : Symmetrical movement of chest wall, bruise (-), bleeding Pal : VF right = left, crepitation (-), pain on palpation (-) Per : sonor right = left, percussion pain (-) Aus : vesicular basic breath sound, wh -/-, rh-/-

AbdomenInsp : flat, hematoma (-), bruise (-),

muscular defense (-)Palp : tenderness, no palpable enlargement on

hepar and spleenPerc : Tympani, pain on percussion (+)Ausc : bowel sound (+) 4x/min

Extremities cap. refill < 2”, warm extremity, edema (-),

bruise (-), hematoma (-),

AMPLE

• Allergy : -• Medication : -• Past Illness: -• Last Meal : 5 hour before accident• Event : fall from motorcycle

Finger in every orifices

• Nose : Blood (-), LCS (-)• Ear : Blood (-), LCS (-) • Mouth : Blood (-)• Anus : Blood (-)• OUE : Blood (-)

Diagnosis

• Vulnus laseratum regio supra orbital sinistra

Treatment

• Non farmakologi: wound toilet and hecting

• Farmakologi: antibiotik dan analgetik

2. R (23 Y.O.)• M: Fall from motorcycle

• I: hematom regio 1/3 medial femur dextra tertutup tanpa gangguan NVD

• S: feel pain at his leg

• T: Patient rode to the hospital with friends

PRIMARY SURVEY

• Patient can talk coherently in a long sentence

• Patient came with his friends


• Airway : Clear• Breathing :

Insp : symmetrical movement of chest wall, bruise (-), RR : 24x/mins

Pal : VF right = left, crepitation (-), pain on palpation (-) Per : sonor right = left, pain on percussion(-) Aus : vesicular basic breath sound, wh -/-, rh-/-

• C = Warm extremities, Pulse = 80 x/min , BP =130/80 mmHg, temperature = 36,5 °C,

capillary refill < 2” • D = GCS 15 – E4V5M6 , pupil isochoric 3 mm / 3

mm, direct light reflex/indirect light reflex +/+, lateralization (-)

• E = There’s no life threatening wound and bruise


2 hour before patient came to the hospital he had motorcycle accident. Patient said he can’t move his leg and feel pain when he move. He said he didn’t remember anything after he fall from the motorcycle. There is no trauma to patient head, patient using helmet the motorcycle speed is 60 km/hour. Headache (-) naussea and vomitting (-)

History of illness

HEAD TO TOE


regio supra orbita sinistraEyes : Round shaped pupil, isochoric 3mm/3mm,



SECONDARY SURVEY

AMPLE

• Allergy : -• Medication : -• Past Illness: -• Last Meal : 4 hour before accident• Event : fall from motorcycle

Rahmat

Diagnosis

• Fraktur 1/3 femur dextra tertutup tanpa gangguan NVD

Treatment

• Non farmakologi: – Hospitalization + surgery plan– Imobilisation with spalk

• Farmakologi: analgetic

NON TRAUMA

1. Tn. S (74 th)

• Chief complain: Lower right abdominal pain

• Additional complain: -

• History of Illness :Patient came to UKI Hospital with complaints of pain lower right abdomen since ± 1 day ago. Pain appears suddenly and is intermittent, prickling pain. Since ± 1 week before admission, the oatient also had the same complaint of pain in the lower right abdomen, pain in the early solar plexus area and then spread. The patient also complained of fever before. Defecation no abnormalities, no urination disorders, nausea and vomiting denied.

General Examination

• Conciousness : composmentis

• Blood Pressure: 140/110 mmHg

• Pulse : 84x/minute

• Respiratory Rate: 18x/minute

• Temp : 36,8o C

HEAD TO TOE


left right nose and on foreheadEyes : Round shaped pupil, isochoric 3mm/3mm,



SECONDARY SURVEY

AMPLE

• Allergy : -• Medication : -• Past Illness: -• Last Meal : -• Event : -

Sulehi

DIAGNOSIS

Suspect Appendicitis kronis

TREATMENT

• Non Medikamentosa

- Hospitalization and surgery plan

- USG appendix

- Fasting

• Medications:

- Antibiotic

1. Ny. L(43 th)

• Chief complain: unconcious• Additional complain: -

• History of Illness :Patient came to UKI Hospital with complaints of unconcious since ± 1 hour ago. For the first time patient complaint about pain around his neck, and then she get home by her self. At the home patient starts to vomitting twice and get unconcious. There is no body at home to see the how the patient become like this. Patient was found by her neighbour. Fever (-) Seizure (-)

General Examination

• Conciousness : unconciousness

• Blood Pressure: 200/100 mmHg

• Pulse : 115x/minute

• Respiratory Rate: 24x/minute

• Temp : 36,3o C

HEAD TO TOE

General ExaminationHead : Bruise (-), edema (-), tumor (-),Eyes : Round shaped pupil, isochoric 3mm/3mm,



SECONDARY SURVEY



hepar and spleenPerc : Tympani, pain on percussion (+)Ausc : bowel sound (+) 6 x/min



AMPLE

• Allergy : -• Medication : -• Past Illness: -• Last Meal : -• Event : unconcious since ± 1

hour ago

DIAGNOSIS

CVD haemoragik + Hipertensi Emergency

TREATMENT• Non Medikamentosa

- Pro craniotomy

- Pro ICU-ventilator

- Fasting

- Observation vital sign

- Pro craniotomy evakuasi

- Head up 300

• Medications:

- Antibiotic

- Analgetic

- Anti perdarahan

- Manitol

- PPI

07022014

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