Emergency Unit

Night Shift Report

February 7th, 2014

TRAUMA

1. E (25 Y.O.)
M: Fall from motorcycle
I: Vulnus laseratum regio supra orbita S: T: Patient rode to the hospital with friends with motorcycle

PRIMARY SURVEY Patient can talk coherently in a long sentence Patient came with his friends

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 = 84 x/min , BP =130/70 mmHg, temperature = 36,5 C, 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

History of illness

1 hour before Patient came to the hospital he had motorcycle accident. Patient didnt use helmet, motorcysle speed is 70 km/hour. Patient said he fall to the right side of motorcycle and his head get hit by trotoar. After the accident patient still concious. Naussea and vomitting denied.

SECONDARY SURVEY
HEAD TO TOE
General Examination Head : Bruise (-), edema (-), tumor (-), wound (+) on regio supra orbita sinistra 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 : tenderness, 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 (-),

AMPLE
Allergy Medication Past Illness Last Meal Event :::: 5 hour before accident : fall from motorcycle

Finger in every orifices

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

Erwin

Diagnosis
Vulnus laseratum regio supra orbital sinistra

Treatment
Non farmakologi: wound toilet and hecting Farmakologi: antibiotik dan analgetik

2. R (23 Y.O.)
M: Fall from motorcycle
I: hematom regio 1/3 medial femur dextra tertutup tanpa gangguan NVD

S: feel pain at his leg

T: Patient rode to the hospital with friends

PRIMARY SURVEY Patient can talk coherently in a long sentence Patient came with his friends

PHYSICAL EXAMINATION
Airway : Clear Breathing :
Insp : symmetrical movement of chest wall, bruise (-), RR : 24x/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 =130/80 mmHg, temperature = 36,5 C, 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

History of illness

2 hour before patient came to the hospital he had motorcycle accident. Patient said he cant move his leg and feel pain when he move. He said he didnt remember anything after he fall from the motorcycle. There is no trauma to patient head, patient using helmet the motorcycle speed is 60 km/hour. Headache (-) naussea and vomitting (-)

SECONDARY SURVEY
HEAD TO TOE
General Examination Head : Bruise (-), edema (-), tumor (-), wound (+) on regio supra orbita sinistra 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 : tenderness, no palpable enlargement on hepar and spleen Perc : Tympani, pain on percussion (+) Ausc : bowel sound (+) 6x/min Extremities cap. refill < 2, warm extremity, edema (-), bruise (-), hematoma (-),

AMPLE
Allergy Medication Past Illness Last Meal Event :::: 4 hour before accident : fall from motorcycle

Finger in every orifices

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

Rahmat

Diagnosis
Fraktur 1/3 femur dextra tertutup tanpa gangguan NVD

Treatment
Non farmakologi:
Hospitalization + surgery plan Imobilisation with spalk

Farmakologi: analgetic

NON TRAUMA

1. Tn. S (74 th)

Chief complain: Lower right abdominal pain Additional complain: -

 History of Illness :
Patient came to UKI Hospital with complaints of pain lower right abdomen since 1 day ago. Pain appears suddenly and is intermittent, prickling pain. Since 1 week before admission, the oatient also had the same complaint of pain in the lower right abdomen, pain in the early solar plexus area and then spread. The patient also complained of fever before. Defecation no abnormalities, no urination disorders, nausea and vomiting denied.

General Examination
Conciousness : composmentis Blood Pressure: 140/110 mmHg Pulse : 84x/minute Respiratory Rate: 18x/minute Temp : 36,8o C

SECONDARY SURVEY
HEAD TO TOE
General Examination Head : Bruise (-), edema (-), tumor (-), wound (+) on left right nose and on forehead 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 : tenderness, 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 (-),

AMPLE
Allergy Medication Past Illness Last Meal Event :::::-

Finger in every orifices

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

Sulehi

DIAGNOSIS

Suspect Appendicitis kronis

TREATMENT
Non Medikamentosa -Hospitalization and surgery plan -USG appendix -Fasting Medications: - Antibiotic

1. Ny. L(43 th)

Chief complain: unconcious Additional complain: -

 History of Illness :
Patient came to UKI Hospital with complaints of unconcious since 1 hour ago. For the first time patient complaint about pain around his neck, and then she get home by her self. At the home patient starts to vomitting twice and get unconcious. There is no body at home to see the how the patient become like this. Patient was found by her neighbour. Fever (-) Seizure (-)

General Examination
Conciousness : unconciousness Blood Pressure: 200/100 mmHg Pulse : 115x/minute Respiratory Rate: 24x/minute Temp : 36,3o C

SECONDARY SURVEY
HEAD TO TOE
General Examination Head : Bruise (-), edema (-), tumor (-), 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 : tenderness, no palpable enlargement on hepar and spleen Perc : Tympani, pain on percussion (+) Ausc : bowel sound (+) 6 x/min Extremities cap. refill < 2, warm extremity, edema (-), bruise (-), hematoma (-),

AMPLE
Allergy Medication Past Illness Last Meal Event ago ::::: unconcious since 1 hour

Finger in every orifices

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

DIAGNOSIS

CVD haemoragik + Hipertensi Emergency

TREATMENT
Non Medikamentosa -Pro craniotomy -Pro ICU-ventilator -Fasting -Observation vital sign -Pro craniotomy evakuasi -Head up 300 Medications: - Antibiotic - Analgetic - Anti perdarahan - Manitol - PPI