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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
AMPLE
• 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”
• 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
• Chief complaint : open wound on supra orbita dextra
• Additional Complaint : -
AMPLE
• Allergy : -• Medication : -• Past Illness : -• Last Meal : in the evening• 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: Basic breath sound Vesicular
right=left, wh-/-, rh-/-.
• Abdomen- Inspection : flat, bruise (-), - Auscultation: bowel sound (+) 8x/min- Palpation : tenderness (-),
defense muscular (-)
- Percussion : tympani, percussion pain (-)
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
TREATMENT• Non Medicamentosa :
- 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 (-)
Thorax :- Inspection : bruise (-), movement of chest wall
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
A
M
P
L
E
• 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”
• Disability– GCS 13 (E4M6V3) pupil isochoric 3/3 mm, centered,
– Direct light reflex/indirect light reflex +/+ • Exposure
There was no life threatening wounds
Secondary Survey
• Chief Complain : multiple wound• Additional Complain : -
AMPLE
• 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 (-),
defense muscular (-)
- Percussion : tympani, percussion pain (-)
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
TREATMENT• Non Medicamentosa :
- 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 )
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