Morpot Rabu 2 Des 2014 Ppt

Emergency UnitNight Shift ReportDecember 2nd 2014Assistant: dr. Agung Aji /dr. Benny

Co-assistant:Ivana Las Maria Sagala (chief)Dumasari Septiana Awardia LydiaOctora YennitaGabriel Hutabarat

Trauma: 4Non Trauma: -Hospitalized: -Non Hospitalized: 4

1. Mrs. W (51 years old)

Mechanism of the Trauma Patient fell from motorcycle to the left side of the road after got hit by a car which suddenly came to the right side of patients motorcycle from the busway lineInjury of target organHeadSymptoms and signs PainTreatment Pre Hospital (Before UKIS ER) None

PRIMARY SURVEY

Airway : CLEARLook: no obstructionListen: no extra breath sound (gurgling (-), snoring (-), stridor (-))Feel: there were warm air from both nose and mouthBreathing : CLEARInspection: bruise (-), chest wall movement symmetrical, RR 24 x/min, hematoma ()Pal : crepitation (-)Per : sonor right = leftAus : basic breath sound bronchial, rh -/-, wh -/-

Circulation : No Sign Of ShockWarm extremitiesBlood pressure 110/80 mmHgPulse = 88x/minuteTemp = 36,80CCRT

Secondary Survey Chief Complain : wound on the forehead around eyesAdditional Complain: -

AMPLEAllergy : -Medication : -Past Illness : -Last Meal : in the eveningEvent : accident

HEAD TO TOEHead: NormocephalyEyes: Pupil circular, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex +/+, CA -/-Ear : Normal, LCS (-), blood (-)Neck : Bruise (-), hematoma (-)

Thorax :Inspection: bruise (-), movement of chest wall symmetrical Palpation: crepitation (-), palpation pain (-)Percussion: sonor right = left, percussion pain (-)Auscultation: vesicular basic breathe sound right=left, wh-/-, rh-/-.

AbdomenInspection: flat, bruise (-), Auscultation: bowel sound (+) 9x/minPalpation: tenderness (-),muscular defense (-)Percussion: tympani, percussion pain (-)

Localized StatusRegio FrontalisLook: Laceration wound, 1cm, edema (-), blood (+), active bleeding (+)Feel: pain on palpation (+)Regio Palpebra inferior sinistra & cantus externaLook : Laceration wound, bleeding (+), active bleeding (-), edem (-)Feel : pain on palpation (+)

History of illnessPatient came to UKIs ER with multiple wound on the forehead and around the left eye as the main problem. She was riding a motorcycle and a car suddenly came towards the right side of patients motorcycle from the busway line and she fell to the left side of the road. During the accident, she was still has the half-face helmet on. Nausea (-), vomit (-), headache (-), seizure (-), multiple wound (+)

Working diagnosisLaceration Wound on the Frontal, External Canthus & Left Bottom Eyelid

TREATMENTNon Medicamentosa :- Non hospitalized- Wound toilet- Wound suturingMedicamentosa : Cefixime 2 x 1 tabDexketoprofen 2 x 1 tabRanitidine 2 x 1 tab

2. Mr. M ( years old)

Mechanism of the Trauma Patient was trying to get out from the truck that was just hit a tank in front of it. But his lower foot was bumped into the steering wheel Injury of target organLower footSymptoms and signs PainTreatment Pre Hospital (Before UKIS ER) None

PRIMARY SURVEY


Circulation : No Sign Of ShockWarm extremitiesBlood pressure 120/80 mmHgPulse = 84 x/menitTemp = 36,3 0CCRT

Secondary Survey Chief complain : pain on the right ankleAdditional complain: wound on the right lower foot

AMPLEAllergy : -Medication : -Past Illness : -Last Meal : in the afternoonEvent : accident

HEAD TO TOEHead: NormocephalyEyes: Pupil circular, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex +/+, CA -/-Ear : Normal, LCS (-), blood (-)Neck : Bruise (-), hematoma (-)

AbdomenInspection: flat, bruise (-), Auscultation: bowel sound (+) 9x/minPalpation: tenderness (-), defense muscular (-)Percussion: tympani, percussion pain (-)

Localized StatusRegio phalanx distal digiti II-III manus dextraLook: laceration wound, 1cm, blood (+)Feel: pain on palpation (+)Movement : active, unlimitedRegio cruris dextraLook: excoration wound, 1 cmFeel: pain (+)Movement : active, unlimitedRegio ankle dextraLook : excoriation wound, 1cmFeel : pain on palpation Movement : limited ( eversion, inversion, plantar & dorso-flexion)

ANKLE X-RAY

History of illnessPatient came to UKIs ER with pain on the right lower foot as the main complain. Patient was driving a truck when it has a stopping problem and hit a tank in front of it. During the accident, patient was trying to get out from the truck but his right foot and hand were trapped and it caused wound and pain. Chest and head trauma, denied. Headache (-), vomit (-), seizure (-), pass-out (-)

Working diagnosisClosed Fracture on the Right Tallus BoneLaceration Wound on Phalanx Media Digiti II-III Manus Dextra

TREATMENTNon Medicamentosa :- Wound suturing (refused)- Back slab immobilization Medicamentosa : Sporetik 2 x 100mgDexketoprofen 3 x 1 tab

3. Mr. R ( 45 years old)

Mechanism of the TraumaPatient jumped from the truck and fell to the ground on a sitting positionInjury of target organPelvicSymptoms and signs Pain, limited movement of the waistTreatment Pre Hospital (Before UKIS ER) None

PRIMARY SURVEY


Secondary Survey Chief complaint : Limited movement on the waistAdditional Complaint: Pain

HEAD TO TOEHead: NormocephalyEyes: Pupil circular, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex +/+, CA -/-Ear : normal, LCS (-), blood (-)Neck : Bruise (-), hematoma (-)

Localized StatusRegio Pelvic & Right PedisLook : blood (-), hematoma (-), edema (-)Feel : pain (+)Movement : limited

Femur X- RAY

PELVIC X-RAY

History of illnessPatient came to UKIs ER with pain and limited movement of the waist as his main problem. He jumped from the truck after realized that his truck had a stopping problem. He jumped and fell to the ground with his bottom hit the ground first ( sitting position ). Passed-out (-), head trauma (-), nausea & vomit (-), pain on the right waist (+)

Working diagnosisRamus superior & inferior Pubical Fracture

TREATMENTNon Medicamentosa :- Pro hospitalized ( refused )- Pelvical & femur CT Scan- Pelvic slingMedicamentosa : Dexketoprofen 3 x 1 tabCefixime 2 x 1 tab

4. Mr. Y ( 24 years old)

Mechanism of the TraumaPatient was punched in the face by several armies Injury of target organFaceSymptoms and signs Pain, woundTreatment Pre Hospital (Before UKIS ER) None

PRIMARY SURVEY


Secondary Survey Chief complaint : Pain and wound palpebra superior & inferior sinistra

Additional Complaint: Swollen area around the eye

HEAD TO TOEHead: NormocephalyEyes: Pupil circular, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex +/+, CA -/-Ear : normal, LCS (-), blood (-)Neck : Bruise (-), hematoma (-)

LOCALIZED STATUSRegio palpebra superior & inferior sinistraLook : hematoma (+), swollen (+)Feel : pain (+)

Regio supercilia sinistraLook : laceration wound , 0,5cm, blood (-)Feel : pain (+)

History of illnessPatient came to UKIs ER with swollen area around the left eye. He was punched by several armies because of his wreckless behaviour when he went to a mall. That incident caused a few wound and bruise on certain part of his body. Active bleeding (-), shortness of breathe (-), headache (-)

Working diagnosisLaceration Wound on the Frontal Region

TREATMENTNon Medicamentosa :- wound toilet- pro hectingMedicamentosa :Cefixime 2 x 1 tabRanitidine 2 x 1 tabMefenamat Acid 2 x 1 tab

*************************

Morpot Rabu 2 Des 2014 Ppt

Documents

Transcript of Morpot Rabu 2 Des 2014 Ppt