Morpot 9 Juni 2013
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Transcript of Morpot 9 Juni 2013
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Emergency Room
Morning Shift ReportJune 19th 2013
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Ms. T ( 25 YO)
M : the left toe crushed by car
I : regio pedis sinistra digiti I
S : pain
T : motorcycle
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Primary Survey
Airway : Clear Breathing :
Insp : bruise (-), chest wall movement
symmetrical, RR 24 x/ min, hematoma (-) Pal : crepitation sub cutis (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right = left
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C = warm extremities, Pulse = 100bpm, BP 130/90 mmHg,
capillary refill time
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History of illness :
Patient came to RSU UKI with the chief complainpain on the left toe. According to the patient,
the pain felt like tingling. Patient was hit by a car
when she walked to cross the street. Her left toewas pinned down under the car tires for about 1
minute. Patient was taken to RS UKI
immediately.
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HEAD TO TOE
Eyes : pupil isochors 3mm/3 mm, centered, direct light
reflex/ indirect light reflex +/+
Ear : Bruise (-), hematoma (-)
Neck : Bruise (-), hematoma (-)
Thorax :
Insp : bruise (-), movement of chest wall symmetrical
Pal : crepitation (-), tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right = left
SECONDARY SURVEY
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Abdomen :
Ins : flat, bruise (-)
Aus : bowel sound (+) 6x/min
Pal : Supel, tenderness (-), muscular
defense (-)
Per : tympani
Extremity:
Warm extremities, cap. refill time < 2,
edema (-)
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Localized StatusRegio Pedis Sinistra Digiti I
Look : vulnus excoriation 2x1cm, active bleeding (-),
cyanosis (+), the nail almost loose Feel : tenderness (+), edema (-)
Move : active (+) passive (+)
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Diagnosis
Closed fracture phalang distal digiti I pedis
sinistra nondisplaced
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TREATMENTWound toilet
Extraction of the nail
AntibioticAnalgetic
Antagonist H2 receptor
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Ms. M (51YO)Chief complain: lower right abdomen pain
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History of illness :
Patient came to the RSU UKI with chief complain
pain in wound trace of operation. The operation,appendectomy was done on 1st June 2013.According to her the pain felt like tingling. The
patient felt more pain when she walked. Pus (-),
blood (-), stich scar good. The pain was spread
until the back. Theres no problem with the
urinate and defecation. Patient already
menopause.
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General StatusGeneral Condition : Mild Illness AppearanceGCS : E4V5M6
BP : 110/70 mmHg
Pulse : 68 bpm
Temp : 36,30 CRR : 18 x/min
Eyes : pupil isochors 3mm/3 mm, centered, direct light reflex/indirect light reflex +/+
Ear : Bruise (-), hematoma (-)Neck : Bruise (-), hematoma (-)
Thorax : Insp : bruise (-), movement of chest wall symmetrical
Pal : crepitation (-), tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right = left
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Abdomen :
Ins : flat, bruise (-)
Aus : bowel sound (+) 8x/min
Pal : Supel, tenderness (+), muscular defense (-)
Per : tympani
Extremity:
Warm extremities, cap. refill time < 2, edema (-)
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DiagnosisPost appendectomy e.c appendicitis chronic
Lower right abdomen pain e.c susp. UTI
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TreatmentAnalgetic
Vitamin B12
Antagonist H2 receptor