EMERGENCY ROOMMORNING REPORTDesember, 2th 2012

1 trauma patients0 non trauma patients

1. Mr R ( YO)M: crushed by carI : digiti I regio pedis dextraS: pain T: car

PRIMARY SURVEYAirway :snooring (-), gargling (-), stridor (-)

Conclusion : airway clearBreathingInspection : bruise (-), chest wall movement symetrical, RR 28 times/minute Palpation : crepitation (-/-), VF right=leftPercusi : sonor +/+ , Auscultation : Basic breath sound vesiculer +/+Conclusion : breathing clear

Primary surveyCirculation : warm extremities, Pulse = 64x/mnt , BP: 130/80mmHg, Temp= 36,70C, capillary refill

Disability GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm, centered, direct light reflex +/+ , indirect light reflex +/+ Conclusion : no head injuryExposure life threatening wounds

History of illnes

30 minutes before admitted to the hospital the patient was riding a motorcycle, when he is at traffic light,his foot crush by a car. Head impact - , abdominal impact -, chest impact -, nausea -, vomiting -, headhache -, amnesia- was, faint - .

Secondary surveyHEAD TO TOEdigiti I regio pedis dextra :Look : vulnus ekskoriasi 5x3cm, swelling (+), bruise (-), active bleeding (+)Feel : pain (+)

Regio antebrachii :Look : vuknus ekskoriasi , clot +, active bleeding -Feel : pain (+)

Abdomen :Ins: Flat, bruise (-) Aus: Bowel sound (+) 4x/minPal: Defence muscular (-)Per: Tympani, percussion pain (-)

AMPLEAllergy : -Medication : -Past illnes : -Last meal : 3 hours agoEvent : crushed by car

WD Traumatic amputation + fraksi microformed tibia dextra

TeraphyWound toiletHectingGips backslap

Mm : Antibiotik Analgetik Ranitidine

2. Mr.A ( 27 YO)Chief complaint : Pain on right lower abdominal Additional complaint : nausea, vomiting, difficult to defecating

History of illness (auto anamnesis) :Approximately 1 month before admittance to the hospital, patient complained that he feels pain in his right lower abdominal. This pain feels continously and didnt spread to another area of abdomen. This pain is relieved by change posisition when he lay down. Before that he admitted that she used to feel pain at the epigastric regio sometimes with nausea . Urinating problem denied, defecating problem he was complaint difficult to defecate for about 1 month ago,blood - , vomitus denied, fever denied.

1 day before admitted to the hospital his complaint pain on right lower abdominal. This complaint more severe than before. She complaint nau vomiting + 2 times that contains fluid.and he got fever , the patient didnt check the temperature, and he went to clinic and he has given medicine for his pain.

General ExaminationGeneral Condition: Moderate illnessConsciousness : Compos mentisBlood Pressure: 190/110 mmHgHeart Rate:80 times/minute, aritmiaResp. Rate:24 times/minuteTemperature:36.8C Anal Temperatur : 37C

GENERAL EXAMINATION

Eyes:conjuntiva anemis -/-, sclera icteric -/-Ear:normotia/normotia, secret -/-Nose:secret -/-Neck:no enlarged lymph glands

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

Abdomen :Ins: flat, bruise (-)Aus: bowel sound (+) 3times/minutePal: tenderness (+) in McBurney pointPer: tympani, percussion pain (-)

Ekstremitas : warm extremities, cap. refill < 2, edema (-)

Abdomen : Right Lower abdominal pain, Tenderness(+) in ,Mc BURNEY Point(+) Psoas Sign (+), Rovsing sign(-) Obturator sign (-),Percussion Pain (-). Local status

DIGITAL RECTAL EXAMINATIONInspetion R. Anal : the colour same with around, skin tag (-), fissura (-), fistel (-)Palpation :TSA : ClampAmpula recti : Not collapsMucosa Retum : slipperyPain : + on 9 10 0clockHandscoon : Fesses (-), blood (-)

LaboratoriumLaboratory examinationHb : 14,9 mg/dLLeukosit : 13,5 thousand /uL Ht : 45,8 %Trombosit : 211 thousand/uLclinical chemistryUreum : 80 Na = 148Creatinin : 1,32 K = 2,8GDS : 124 Cl = 101

DIAGNOSIS

Apendisitis Cronis acute exacerbation

TREATMENTPatient hospitalizedPro appendectomyAntibiotikH2 reseptor antagonist

3. Mrs A (58YO)M : fall when walking to bathroomI : regio palbebra superior et inferior sinistra, regio buccal sinistra, regio maxilla sinistra.S : pain on woundT : car

PRIMARY SURVEYAirway :snooring (-), gargling (-), stridor (-)

Conclusion : airway clearBreathingInspection : bruise (-), chest wall movement symetrical, RR 22 times/minute Palpation : crepitation (-/-), VF right=leftPercusi : sonor +/+ , Auscultation : Basic breath sound vesiculer +/+Conclusion : breathing clear

Primary surveyCirculation : warm extremities, Pulse = 80x/mnt , BP: 220/110mmHg, Temp= 36,80C, capillary refill

Disability GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm, centered, direct light reflex +/+ , indirect light reflex +/+ , bruise (+) at regio periorbital sinistra, regio buccal sisnistra and regio maxilla sinistraConclusion : head injuryExposure no life threatening wounds

History of illnes 1 day before admitted to the hospital, when the patient was walking to the bathroom when she suddenly slipped and fell. Head impact + ,bruises(+),than patient feel sweeling in her face. abdominal impact -, chest impact -, nausea -, vomiting -, headhache -, amnesia- , faint .

Secondary surveyHEAD TO TOERegio periorbita sinistraLook : swelling (+), bruise (-), active bleeding (-)Feel : pain (+)Regio buccal sinistraLook : swelling (+), bruise (-),excoriation(+) active bleeding (-)Feel : pain (+), krepitasi (+)Regio maxilla :Look : swelling (+), bruise (-) active bleeding +Feel : pain (+)

Abdomen :Ins: flat, bruise (-) Aus: bowel sound (+) 4x/minPal: defence muscular (-)Per: tympani, percussion pain (-)

AMPLEAllergy : -Medication : captoprilPast illnes : hyistory of hypertensionLast meal : 3 hours agoEvent : slipped ang fell down.

Toraks

WDICH + Ventrikulmegali + Hematom regio orbita zygoma labialis sinistra + hipertensi heart disease

5. Mr.S ( 27 YO)Chief complaint : Pain on right lower abdominal Additional complaint : nausea, vomiting, difficult to defecating

History of illness (auto anamnesis) :Approximately 4 days before admittance to the hospital, patient complained that he feels pain in his right lower abdominal. This pain feels like stabbed, continously and didnt spread to another area of abdomen. This pain is relieved by change posisition when he lay down. Before that he admitted that he used to feel pain at the epigastric regio sometimes with nausea . Urinating problem denied, defecating problem he was complaint difficult to defecate since about 2 day ago, vomitus denied, fever denied.

1 day before admitted to the hospital his complaint pain on right lower abdominal. This complaint more severe than before. He complaint nausea, vomiting + 2 times that contains fluid.and he got fever , the patient didnt check the temperature, and he went to clinic and he has given medicine for his pain.

General ExaminationGeneral Condition: Moderate illnessConsciousness : Compos mentisBlood Pressure: 150/100 mmHgHeart Rate:88 times/minuteResp. Rate:20 times/minuteTemperature:36.8C Anal Temperatur : 37C

GENERAL EXAMINATION

Eyes:conjuntiva anemis -/-, sclera icteric -/-Ear:normotia/normotia, secret -/-Nose:secret -/-Neck:no enlarged lymph glands

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

Abdomen :Ins: flat, bruise (-)Aus: bowel sound (+) 3times/minutePal: tenderness (+) in McBurney pointPer: tympani, percussion pain (-) Ekstremitas : warm extremities, cap. refill < 2, edema (-)

Abdomen : Right Lower abdominal pain, Tenderness(+) in ,Mc BURNEY Point(+) Psoas Sign (+), Rovsing sign(-) Obturator sign (-),Percussion Pain (-). Local status

DIGITAL RECTAL EXAMINATIONInspetion R. Anal : the colour same with around, skin tag (-), fissura (-), fistel (-)Palpation :TSA : ClampAmpula recti : Not collapsMucosa Retum : slipperyPain : -Handscoon : Fesses (-), blood (-)

DIAGNOSIS

Susp Apendisitis acute

TREATMENTPatient hospitalizedAntibiotikH2 reseptor antagonist