Morpot Bedah 12 Nov 2014 Ppt

transcript

Emergency Unit

Night Shift ReportNovember, 12th 2014

Assistant:dr. Agung Aji / dr. Benny

Co-assistant:Awardia Lydia (chief)

RikiIvana Las Maria

Innestyas ChrisantyFrancisca N. M. S

Natalia

• Trauma: 4• Non Trauma: 2

• Hospitalize: 4• Non Hospitalize: 2

4.Mr. AG ( 21 years old)25.05.06.00

Mechanism of the TraumaPatient hit another motorcycle from the contraflow and was thud onto the asphalt. The anteriorof the body was hit the ground first. Patient wasthud around 1m from the crash spot. Injury of target organScalp and left nasolabialis Symptoms and signs Pain (+)Treatment Pre Hospital (Before UKI’S ER)Sutured wound & verband on the right back side of the head

PRIMARY SURVEY

• Airway : CLEAR– Look : no obstruction– Listen : no extra breath sound (gurgling (-), snoring (-), stridor (-))– Feel : there were warm air from both nose & mouth

• Breathing : CLEAR– Inspection: bruise (-), chest wall movement symmetrical, RR 22 x/min, hematoma (–)– Pal : crepitation (-)– Per : sonor right = left– Aus :vesicular basic breathe sound, rh -/-, wh -/-

• Circulation : No Sign Of Shock– Warm extremities, blood pressure 100/80mmHg– Pulse = 82 x/menit– Temp = 360C– CRT <2”

• Disability– GCS 13 (E4M6V5) pupil isochoric 3/3 mm, centered,

– Direct light reflex/indirect light reflex +/+ • Exposure

There was no life threatening wounds

Secondary Survey

• Chief Complain : headache• Additional Complain : vomit once, seizure once

• Allergy : -• Medication : -• Past Illness : -• Last Meal : in the morning• Event : 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-/-.

• Abdomen- Inspection : flat, bruise (-), - Auscultation: bowel sound (+) 9x/min- Palpation : tenderness (-),

muscular defense(-)

- Percussion : tympani, percussion pain (-)

Localized Status• SCALP• L : Vulnus laceratum, ±2cm, suture (+), verband (+)• F : nyeri (+)

• Nasolabialis Region • L : Vulnus laceratum ± 2cm• F : pain (+)

Ct scan

History of illness

• Patient came to UKI’s ER with headache after had a motorcycle accident. He was on a fast velocity. From the contra flow, there was another motorcycle and the both crashed and patient was thud onto the road ± 1m from the crash spot. Vomit (+), seizure (+) 1x

Working diagnose

Mild Head Injury + Cerebral oedema + Cerebral Contusion Frontalis and Occipitalis Region + Epidural haematoma right parietal

region

TREATMENT• Non Medicamentosa :

- Hospitalized- ICP & vital signs observation- Head up 30°+ O2 face mask 8 lpm

• Medicamentosa :• IVFD : RL/24 hours + 3 amp Dexketoprofen• RL/24 hours + 1 amp Ikaneuron

Ceftriaxone 2 x 1mg Ranitidine 2 x 1amp Plasminex 3 x 1 amp Vit. K 1 x 1 amp Ergotica 2 x 1 tab

1. Mr. M ( 6 years old)29.09.06.00

Mechanism of the TraumaFall in the bathroomInjury of target organSupra Orbita DextraSymptoms and signs Open wound Treatment Pre Hospital (Before UKI’S ER)verban

PRIMARY SURVEY

• Airway : CLEAR– Look : no obstruction– Listen : no extra breath sound (no gurgling, no snoring, no stridor)– Feel : there were warm air from both nose and mouth

• Breathing : CLEAR– Inspection: bruise (-), chest wall movement symmetrical, RR 20 x/min, hematoma (–)– Pal : crepitation (-)– Per : sonor right = left– Aus : Basic breath sound bronchial, rh -/-, wh -/-

• Circulation : No Sign Of Shock– Warm extremities,– Pulse = 96 x/menit– Temp = 360C– CRT <2”

Secondary Survey

• Chief complaint : open wound on supra orbita dextra

• Additional Complaint : -

• Allergy : -• Medication : -• Past Illness : -• Last Meal : in the evening• Event : accident

(-)- Auscultation: Basic breath sound Vesicular

defense muscular (-)

Localized Status

• Regio supra orbita dextra

Look: Vulnus Laceratum , 1 wounds ±( 4 cm),wound basic subcutis, edema (-), hematoma (-), blood (+), active bleeding (-), pus (-)

Feel: pain on palpation (+), Movement: unlimited

History of illness

• Patient came to UKI’s ER in case of Trauma. Patient have a pain on supra orbita dextra. 4 hours before admitted to UKI, patient was falling in the bathroom while he took a shower. Patient fell with prone position. The patient still remembered the event. Head injury denied, chest injury denied. Dizziness (-), unconsciousness and vomitting was denied.

Working diagnose

Vulnus Laseratum supra orbita dextra

- Non – hospitalized- Wound toilette- Hecting

• Medicamentosa :– Sporetik syr 2x1C

2. Mr. DB ( 9 years old)26.09.06.00

Mechanism of the TraumaPatient fall from the treeInjury of target organLeft headSymptoms and signs Open wound on the left headTreatment Pre Hospital (Before UKI’S ER)-

PRIMARY SURVEY

• Airway : CLEAR– Look : no obstruction– Listen : no extra breath sound (no gurgling, no snoring, no stridor)– Feel : there were warm air from both nose and mouth

• Breathing : CLEAR– Inspection: bruise (-), chest wall movement symmetrical, RR 22 x/min, hematoma (–)- Pal : VF right = left – Per : sonor right = left, , percussion pain (+) on IC 5 and 6– Aus : Basic breath sound vesiculer, rh -/-, wh -/-

• Circulation : No Sign Of Shock– Warm extremities,– Blood preasure : 110/70 mmHg– Pulse = 98 x/menit– Temp = 36,50C– CRT <2”

• Disability– GCS 15 (E4M6V5) pupil isochoric 3/3 mm,

centered, – Direct light reflex/indirect light reflex +/+

• Exposure There was no life threatening wounds

Secondary survey

HEAD TO TOEHead : normocephali, open wound on the right

temporoparietal regionEyes : Pupil circular, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect Light Reflex +/+, CA -/-Ear : normal, LCS (-), blood (-)Neck : hematoma (-)

symmetrical - Palpation : VF right = left- Percussion : sonor right = left, percussion pain

(-) Auscultation: Basic breath sound Vesicular right=left, wh-/-, rh-/-.

• Abdomen- Inspection : flat, bruise (-), - Auscultation: bowel sound (+) 9x/min- Palpation : tenderness (-) on the upper

right abdomen, defense muscular (-)- Percussion : tympani, percussion

pain (-) on the upper right abdomen

• Extremities : warm, CRT < 2s, edem -/-

Secondary Survey

• Allergic : -• Medication : -• Past Illness : -• Last meal : afternoon• Event : accident

• Chief complaint : open wound on the left head

• Additional Complaint : -

History of illness

• Patient came to RSU UKI ER with main complaint open wound on the left part of head. Patient was falling from tree when he took a guava fruits. Patient fell with position. The wound little bleeding. 1 hours ago. Dizziness and vomitting was denied. Unconsciousness (-)

Localized status• Regio temporal sinistra • L : open wound on temporal

sinistra region ± 3cm, bleeding (+) swelling (+)

• F : pain (+), crepitation (-)

Ct scan

Working diagnose

- Mild head injury- vulnus laceratum regio parietalis sinistra-Oedema serebri-Simple fracture (tabula os frontalis sinistra)

TREATMENT• Hospitalized• IVFD: RL/24 jam +manitol 60 cc• Head up 30º• O2 2 Lpm • Konsul terapi bagian anakNon Medicamentosa : - wound toilet - Hecting Medicamentosa :Ceftriaxone 2x1 gr (iv)Ranitidin 2x 30 mg(iv)Ketorolac (vial) tab 10 mg 3x1 tabBrain Vit 1x1 cth

3. Mr. S ( 61 years old)29.09.06.00

Mechanism of the TraumaPatient fell onto the asphalt after a garbage truckhit his porridge cart. His body hit the groundfirst and the head afterInjury of target organRight side of the head and facial regionSymptoms and signs PainTreatment Pre Hospital (Before UKI’S ER)None

PRIMARY SURVEY

• Airway : CLEAR– Look : no obstruction– Listen : no extra breath sound (gurgling (-), snoring (-), stridor (-))– Feel : there were warm air from both nose & mouth

• Breathing : CLEAR– Inspection: bruise (-), chest wall movement symmetrical, RR 16 x/min, hematoma (–)– Pal : crepitation (-)– Per : sonor right = left– Aus : vesicular basic breathe sound, rh -/-, wh -/-

• Circulation : No Sign Of Shock– Warm extremities, blood pressure 180/100mmHg– Pulse = 70 x/menit– Temp = 360C– CRT <2”

Secondary Survey

• Chief Complain : multiple wound• Additional Complain : -

• Allergy : -• Medication : -• Past Illness : -• Last Meal : in the morning• Event : accident

(-)- Auscultation: vesicular basic breathe sound

defense muscular (-)

Localized Status

• Regio Parietal Dextra• L : vulnus laceratum, ± 2,5cm, active bleeding (-),

subcutaneous wound base• F : pain (+)• Regio Frontalis• L : vulnus laceratum, ± 3cm, active bleeding (-),

subcutaneous wound base• F : pain (+)• Regio Zygoma Dextra• L : vulnus laceratum, ± 1cm, active bleeding (-),

cutaneous wound base• F : Pain (+)

History of illness

• Patient came to UKI’s ER with multiple wound on the face and the head. He was standing beside his porridge cart, from the back side of the cart, a garbage truck suddenly hit the cart and patient got dragged by the cart and fell to the back, onto the asphalt. His body was the first hit the ground and his head after. He was brought to the hospital right away. Dizzyness (+), vomit twice.

Working diagnose

Mild Head Injury + Epidural Haematoma Temporoparietal Right Region + Multiple

Vulnus Laceratum

- Hospitalized- ICP and vital signs observation- Head up 30°+ O2 face mask 8 lpm- Hecting

• Medicamentosa :• IVFD : RL/24 hours + 3 amp Dexketoprofen• RL/24 hours + 2 amp Co-dergocrine Mesylate + 1 amp

Ikaneuron Ceftriaxone 2 x 1mg Ranitidine 2 x 1amp Plasminex 3 x 1 amp Vit. K 1 x 1 amp Manitol 4 x 100 drip

5. Mr. M (47 Years Old) 23.14.04.00

Chief complainUlcer on right leg

Additional complainFever

History of present illness: Patient came to the ER with the complaints of a ulcer on leg since 7 days before admission. Patient didn’t know the reason of the ulcer. on the beginning the ulcer is small and become bigger day to day, especially on last 2 days. Patient feel pain on the leg. Patient had give an oinment but it didn’t work. Fever (+) vomiting (-), dizzy (-), headache (-)

General ExaminationGC : Look mildly sickConsciousness: E4M6V5 GCS 15 pupil circular,

isochoric 3mm/3mm, centered, DLR +/+, ILR +/+,

Vital signBP : 130/90 mmHgHR : 70 b/mRR : 22 b/mT : 37,6°C

Thorax :Insp : movement of chest wall

symmetrical Pal : vocal fremitus right = left Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer

right=left

• Abdomen:– Inspection: looks flat– Ausculatation: bowel sounds 8x/m– Palpation: palpation pain (-) – Percussion: percussion pain (-) on the

lower abdomen

• Extremities: warm acral, crt < 2s

Localized status

• Regio cruris dextraL: ulcer on the cruris

dextra, 5 x 4 cm, eritem, rough surface, swelling

F: warm, pain +, fluctuation +

Diagnosis

Abses cruris dextra posterior

Treatment

• Non Medicamentosawound toilethospitalized

• IVFD : 1 RL/24 hours• Medicamentosa- Meropenem 2 x 200 mg- Metronidazol drip 3 x 1- Paracetamol 3 x 500 mg k/p

Ms. D (22 years old)MR 43.02.06.00

• Chief complain : Pain of the abdominal right lower quadrant.

• Additional Complain : -

History of Present Illness

Patient was brought by her mother to ER RSUKI with complained of pain in the abdominal right lower quadrant since three days ago. Patient felt pain centre of the abdomen, to the left abdomen, to left lower quadrant then to right lower quadrant of the abdomen. Patient had came to clinic and doctor gave the medicine but there wasn’t progress of the complain.

Since nine hours ago, the paint get worse. Vomit +. Nausea +. Dizziness -.

GENERAL EXAMINATION

• General Condition: moderately ill• GCS: E4M6V5• BP: 140/110 mmHg• Pulse Rate: 96x/minute• RR: 22x/minute • Temperature: 37°

LOCALIZED STATUSGENITAL AREA (Regio Iliaca Dextra)

LOCALIZED STATUS

Regio Iliaca Dextra:I : flatP : tympani, percussion pain (-)P : rebound pain (+) on mcburney point

Working diagnose

Susp. Acute Appendicitis

TREATMENT

• Hospitalized• IVFD : RL/ 24 hours• Mm/ Meropenem 2 x 200 mg ( IV )

Ranitidine 2 x 1 amp ( IV )

THANKYOU

Morpot Bedah 12 Nov 2014 Ppt

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