Emergency Room

Night Shift Report

December, 18th 2015
Assistant :
dr. Kezia
Team 2

I Nyoman Yesaya
Noven Zefanya
Dumasari Septiani
Meylani Bith
Stephanie Talilah
Carla Putri
Kadek Widhiana
Rani Septiani
Ririn Purba
Kezia Miracle
Sarah
Clara Gabriele
Filologus Siwabessy
Firman Siregar
Rico Panggabean

Traumatic
: 2
Hospitalized : 0
Non Traumatic : 0
Non Hospitalized : 1

1. Ms. H (19 YO)

History of Illness
Chief Complain : Right shoulder pain
Patient came to RS UKI with chief
complain right shoulder pain since
30 minutes ago. The pain felt
continously and increasingly when
she moves her hand. Its happened
when she rode a motorcycle and
crushed by other motorcycle then
she fell down with right shoulder hit

Vital Sign
General Appearance : Moderate Illness
Consciousness : Composmentis
Blood Pressure : 130/80mmHg
Pulse
: 88x/min
Respiratory Rate : 22x/min
Temperature : 36,5C

PRIMARY SURVEY
Airway :

No snorring, no gurgling,no stridor = clear

Breathing
Insp : movement of chest wall symmetrical, bruise (-),
RR : 22 x/min
Pal : vocal fremitus symmetris, crepitation (+)
Per : sonor right = left
Aus : Basic breath sound vesicular
Conclusion : clear

Primary Survey
C :

Warm extremitas, pulse 88 x/mnt, BP :

130/80mmHg, CRT <2

D :

GCS 15 E4V5M6, pupil round, isochoric

3mm / 3mm,

centered, direct light reflex +/+,

indirect light reflex +/+

E : Excoriation wound

AMPLE

Allergy
:Medication
:Past Illness
:Last Meal : Event
: fell from motorcycle

SECONDARY SURVEY
HEAD TO TOE
Head: normocephali, conjungtiva anemis -/-, sclera
icteric -/Bruise (-), blood (-), oedem (-)
Eyes : Pupil round, isochoric 3mm/3mm, centered,
direct Light Reflex +/+, Indirect Light Reflex
+/+
Neck : Bruise (-), hematom (-), enlarged lymph
nodes (-)

Thorax :
Insp : bruise (-) , movement of chest wall
symmetrical,
Pal : crepitation (+)
Per : sonor /sonor

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

Extremity
Warm extremity, capillary refill time < 2 secs,
-/-

Localized status
Regio clavicula dextra
L : Hematom (-), vulnus (-)
F : Crepitation (+) edema (-) tenderness (+)
M : Limited
Regio patella sinistra
L : Wound excoriation, hematom (-)
F : Crepitation (-) edema (-) pain (+)
M : (+)

Localized status
Regio pelvic
L : wound excoriation, active bleeding (-) hematom (-)
F : Crepitation (-) edema (-) pain (+)
M : (+)

DIAGNOSIS
Closed fracture medial
clavicula dextra without
NVD disorders +
multiple vulnus
excoriation

TREATMENT
- Wound toilet
- Pro Orif
- Reference to POLRI
Hospital

2. Mrs. M (58 YO)

History of Illness
Chief Complain : Left shoulder pain
Patient came to RS UKI with chief complain
left shoulder pain since 1 hour ago. The
pain felt continuously and increasingly
when she moves her hand.
Initially the patient fell out of the train with
his left hand sustaining the fall. Patient
head do not collide. After the incident,
patient still fully conscious. Fainted (-),
vomiting (-), headache (-). Patients was
given first aid at the clinic with a splint.

Vital Sign
General Appearance : Severe Illness
Consciousness : Composmentis
Blood Pressure : 180/110mmHg
Pulse
: 82x/min
Respiratory Rate : 20x/min
Temperature : 36,4C

PRIMARY SURVEY
Airway :

No snorring, no gurgling,no stridor = clear

Breathing
Insp : movement of chest wall symmetrical, bruise (-),
RR : 20 x/min
Pal : vocal fremitus symmetris, crepitation (-)
Per : sonor right = left
Aus : Basic breath sound vesicular
Conclusion : clear

Primary Survey
C :

Warm extremitas, pulse 82 x/mnt, BP :

180/110mmHg, CRT <2

D :

GCS 15 E4V5M6, pupil round, isochoric

3mm / 3mm,

centered, direct light reflex +/+,

indirect light reflex +/+

E : Theres no life threatening injuries

AMPLE

Allergy
:Medication
:Past Illness
:Last Meal : Event
: fell from train

SECONDARY SURVEY
HEAD TO TOE
Head: normocephali, conjungtiva anemis -/-, sclera
icteric -/Bruise (-), blood (-), oedem (-)
Eyes : Pupil round, isochoric 3mm/3mm, centered,
direct Light Reflex +/+, Indirect Light Reflex
+/+
Neck : Bruise (-), hematom (-), enlarged lymph
nodes (-)

Thorax :
Insp : bruise (-) , movement of chest wall
symmetrical,
Pal : crepitation (-)
Per : sonor /sonor

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

Extremity
Warm extremity, capillary refill time < 2 secs,
-/-

Localized status
Regio brachii & ante brachii sinistra
L : Hematom (-), vulnus (-)
F : Crepitation (-) edema (-) tenderness (+)
M : Limited
Regio cruris sinistra
L : Hematom (-), vulnus (-)
F : Crepitation (-) edema (+) pain (+)
M : Limited

DIAGNOSIS
??????
Closed fracture medial
clavicula dextra without
NVD disorders +
multiple vulnus
excoriation

TREATMENT
- ??????
- Pro Orif
-