Emergency Unit

Night Shift Report

January 31st, 2014

1. Mr. SA (32 Y.O.)

M: Fell from the motorcycle I: Vulnus laceratum regio genu dextra S: Pain on the right knee

T: Patient came with motorcycle

PRIMARY SURVEY Patient can talk coherently in a long sentence Patient came alone

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-/-

PHYSICAL EXAMINATION

C = Warm extremities, Pulse = 80 x/min , BP =120/80 mmHg, temperature = 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 and bruise

SECONDARY SURVEY
HEAD TO TOE
General Examination Head : Bruise (-), edema (-) tumor (-), wound (-) Eyes : 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

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-/-

Abdomen Insp : flat, hematoma (-), bruise (-), muscular defense (-) Palp : smooth, no palpable enlargement on hepar and spleen Perc : Tympani, pain on percussion (-) Ausc : bowel sound (+) 4x/min Extremities cap. refill < 2, warm extremity, edema (-), bruise (+), hematoma (-), wound (+)

 Extremites Superior wound (+) Vulnus excoriasis regio dorsum manus dextra. Extremites Superior wound (+) Vulnus excoriasis regio pedis dextra, vulnus laceratum regio genu dextra

AMPLE
Allergy Medication Past Illness Last Meal Event :::: several hours ago :-

Finger in every orifices

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

 Chief complain : pain on right knee Additional complain: no complain

 History of Illness :
Patient came with pain on right knee. Pain felt after he fell down on the street while riding on his motorcycle, trying to avoid a hole on the street but he lost control of his motorcycle. He fell to his right side, making bruises on his right knee. Dizziness and vomit were denied

DIAGNOSIS

Vulnus laceratum regio genu dextra

TREATMENT
Non Medikamentosa -Necrotomie and debridement -Hecting Medications: Antibiotic Analgetic H2 blocker

2. Mr. RF (32 Y.O.)

M: Fighting I: Vulnus punctum, vulnus escoriasi, pneumothorax S: Difficulty of breathing T: Patient came with his parents

PRIMARY SURVEY Patient is conscious Patient came with his parents

PHYSICAL EXAMINATION
Airway : Clear Breathing :
Insp : asymmetrical movement of chest wall, the right one is left behind, bruise (-), RR : 35x/mins Pal : crepitation (-), pain on palpation (-) Per : dull on the right, sonor on the left, pain on percussion (-) Aus : vesicular basic breath sound, wh -/-, rh-/-

PHYSICAL EXAMINATION

C = Warm extremities, Pulse = 96 x/min , BP =100/70 mmHg, temperature = 36C, capillary refill < 2 D = GCS 15 E4V5M6 , pupil isochoric 3 mm / 3 mm, direct light reflex/indirect light reflex +/+, lateralization (-) E = Theres wound on the right chest 2 cm

SECONDARY SURVEY
HEAD TO TOE
General Examination Head : Bruise (-), edema (-) tumor (-), wound (-), hematoma diameter 1 cm Eyes : 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, wound (+) stabbing wound on the nape of the neck size 1,5 cm

Thorax Insp : Asymmetrical movement of chest wall (the right one is left behind), bruise (-), bleeding (-), wound (+) on right chest 2 cm Pal : crepitation (-), pain on palpation (-) Per : dull on the right, sonor on the left, pain on percussion (-) Aus : vesicular basic breath sound, wh -/-, rh-/-

Abdomen Insp : flat, hematoma (-), bruise (-), muscular defense (-) Palp : smooth, no palpable enlargement on hepar and spleen Perc : Tympani, pain on percussion (-) Ausc : bowel sound (+) 4x/min Extremities cap. refill < 2, warm extremity, edema (-), bruise (+), hematoma (-), wound (-)

AMPLE
Allergy Medication Past Illness Last Meal Event :::: several hours ago :-

Finger in every orifices

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

 Chief complain

: stabbing wound on right chest Additional complain: difficulty breathing

 History of Illness :
Patient came with stabbing wound on right chest since 1 hour before came to the hospital. Patient was involved on a riot near his house and he was attacked on the right chest and also on the nape of his neck, making a stabbing wound 2 cm and 1,5 cm. Before came to RS UKI patient was taken to RS Yadika but didnt get treated so his parents took him to RS UKI

DIAGNOSIS
Tension pneumothorax with improvements Vulnus punctum regio hemithorax dextra Vulnus punctum regio colli posterior Multiple vulnus excoriasis

TREATMENT
Non Medikamentosa - Hospitalization - O2 + nasal canul 4 lpm - Catheter - IVFD: 1 RL + 2 amp ergot alkaloids 1 electrolyte + 3 amp analgetic Medications: Antibiotic Analgetic H2 blocker