Emergency Room

Night Shift Report

M AY, 1 3 T H 2 0 1 1

1 patient trauma

1. child A (1 1/2 YO)

PRIMARY SURVEY
Self protection (gloves)
Collar neck Patient was brought by policeman friend because motorcyle accident

Airway : Clear Breathing :

Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on posteriolateral sinistra proximately at costae 6 Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae 5 Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/- , rh-/+

 C = warm extremities, Pulse = 80 x/min , BP =

120/80 mmHg,Temp = 36,5c, capillary refill < 2 D = GCS 15 E4V5M6, pupil isochoric 3 mm / 3 mm, direct light reflex/indirect light reflex +/+, lateralization (-) E = Theres no life threatening wound

Secondary Survey 1. Mr. IN (15 YO)

Chief complaint
Additional complaint

: pain at left forehead : pain at left chest when the patient was breathing

SECONDARY SURVEY
History of illness :

30 minutes before admittated to the hospital, the patient was

riding the motorcycle with estimated speed 40 km/h and then she was hit the busway separator. Suddenly she was fall from the motorcycle and patient full-faced helm was off from her head. Her left side (head and chest) was hit the asphalt. After fall from the motorcycle patient was unconscious 1 minute, after that patient woke up and then she unconscious again in less 1 minute. Patient complaining about the pain in her left temples and left chest, amnesia retrogade (+), nausea (-), vomiting (-), headache (-). Patient was taken to the hospital by police man after she woke up again.

AMPLE
Allergy Medication Past Illness

Last Meal
Event

:::: 3 h before an accident : motorcycle Accident

HEAD TO TOE

General Examination GC : Look mild illness E4V5M6 compos mentis BP : 120/80mmHg HR : 80x/m RR : 20x/m T : 36,5C Head : Bruise -, Hematom -, tumor -, blood Nose : normal, blood -, LCS Eyes : Pupil round, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex +/+

Ear Neck Thorax

: normal, LCS -, blood : Bruise (-), hematom (-), nn.ll no palpable enlarge

Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on posteriolateral sinistra proximately at costae 6 Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae 5 Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/, rh-/+

Abdomen Ins : flat, hematom (-), bruise (-), defence muscular (-) Pal : tenderness (-) Per : Percusion tenderness (-), Tympani Aus : bowel sound + 4x/m
Ekstremitas cap. refill < 2, edema (-), warm extremity,excoriasi regio right elbow, dorsum pedis dextra.

Localized status

 Regio frontotemporal

Infra orbita

L : vulnus laceratum size o,5x0,5 cm bruise (-), oedem (+), hematome (+), active bleeding (-), passive bleeding (+), F : tenderness (+), crepitation (-) M : crepitation -

L : excoriasi 2x2 cm bruise (-), oedem (-), hematome (-), active bleeding (-), passive bleeding (-), F : tenderness (+), crepitation (-) M : crepitation -

DIAGNOSA
moderate head injury + oedem cerebri + contusio thorax

Foto x-ray

CT-scan

CT-scan

TREATMENT
Hospitalized O2 nasal kanul 3 lpm IVFD : MM/ : antibiotic antiemetic analgetic haemostatic

3. Mr. S (60 YO)

Chief complaint

: bleeding from the nose and : pain in the right shoulder

mouth Additional complaint

PRIMARY SURVEY
Self protection (gloves) Collar neck Patient was brought by policeman because motorcyle accident

Airway : Clear
Breathing :
Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) Pal : crepitation (-), pain on palpation (-) Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/- , rh-/

 C = warm extremities, pulse = 78 x/min , BP =

140/100 mmHg, temp = 36,5c, capillary refill < 2 D = GCS 15 E4V5M6, pupil isochoric dificult to asses, direct light reflex/indirect light reflex +/+, lateralization (-) E = Theres no life threatening wound

Secondary survey
History;

one half hour before entering the hospital the patient

was driving a motor with a speed of 40 km / h, and then plunged the hole and was thrown approximately one meter. Patients using the halffaced helmet, but the helmet came off and his face hit the asphalt. vomiting + (contains 10 cc of blood), nausea -, fainting -, collision chest +, + the head clash, collision abdominal -.

AMPLE
Allergy : -

Medication : Past illness : Last meal : 9 h before accident

Even : traffic accident

Head to toe
General Examination GC : Look moderate illness E4V5M6 compos mentis BP : 140/100mmHg HR : 78x/m RR : 20x/m T : 36,5C Head : Bruise +, Hematom +, tumor -, blood + Nose : normal, blood -, LCS Eyes : Pupil round, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Reflex +/+

Light

Ear Neck Thorax

: normal, LCS -, blood : Bruise (-), hematom (-), nn.ll no palpable enlarge

Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on posteriolateral sinistra proximately at costae 6 Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae 5 Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/, rh-/+

Abdomen Ins : flat, hematom (-), bruise (-), defence muscular (-) Pal : tenderness (-) Per : Percusion tenderness (-), Tympani Aus : bowel sound + 4x/m

Ekstremitas cap. refill < 2, edema (-), warm extremity,excoriasi regio right elbow, dorsum pedis dextra.

Localized status
Regio Orbitalis Dextra

L : oedem (+), hematome (+), active bleeding (-), passive bleeding (+), F : tenderness (+), crepitation (-)

Regio zygoma Dextra

L : excoriasi 2x2 cm bruise (-), oedem (-), hematome (-), active bleeding (-), passive bleeding (-), F : tenderness (+), crepitation (-)

: crepitation -

 Regio frontalis dextra

L : excoriasi 6x2 cm the base is soft tissue, oedem (-), hematome (-), active bleeding (-), passive bleeding (+), F : tenderness (-), crepitation (-)

: crepitation

Regio nasalis

L : bleeding from the nose, active bleeding (+), passive bleeding (-) F : tenderness (-), crepitation (-)

: crepitation

 Regio oris

L F

: blood +, active bleeding (+), passive bleeding (-) : tenderness (-), crepitation (-)

diagnosa
mild head injury

Thorax Foto