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Emergency Unit

Night Shift ReportMarch, 8th 2013

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1. Mr. J( 21 YO )

PRIMARY SURVEY

M: Finger trapped on asphalt makerengine

I : Regio Parietal S : Pain on hand

T : -

Patient can talk coherently in a longsentence

Patient was brought by her family

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PHYSICAL EXAMINATION

Airway : Clear

Breathing :Insp : movement of chest wall symmetrical, bruise (-),

RR : 20 x/mins

Pal : crepitation (-), tenderness (-)

Per : sonor right = left, tenderness on percussion(-)

Aus : Basic breath sound vesicular

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C = Warm extremities, Pulse = 84 x/min ,

BP =120/80 mmHg, temperature = 36,5 C, capillaryrefill time< 2

D = GCS 15 E4M6V5 , pupil isochoric 3 mm / 3

mm, direct light reflex/indirect light reflex +/+ E = Theres no life threatening wound

PHYSICAL EXAMINATION

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SECONDARY SURVEY

Chief complaint : Pain on left hand.

Additional complaint : -

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SECONDARY SURVEY

History of Illness :The patient complain pain on his finger

since 2 hours and 30 minutes ago. His

finger was trapped on the asphalt makerengine. Active bleeding ( + ).

Head impact (-), Chest impact (-),

Abdominal impact (-), shortness of breath

(-), unconsciousness (-), amnesia (-),

headache (-), vomit (-), nausea (-).

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AMPLE

Allergy : -

Medication : antiseptic

Past Illness : -

Last Meal : 4 hours before admitted

hospital

Event : Accident

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HEAD TO TOE

General Examination

GC : Look mild illness

E4M6V5 compos mentis

BP : 120/80 mmHg

HR : 84x/m

RR : 20x/m

T : 36,5C

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Head : Normocephali

Eyes : Pupil round, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+,

Indirect Light Reflex +/+, CA-/-,

SI-/-

Neck : Bruise (-), hematoma (-),

Face : Wound (-), Hematoma (-)

Thorax

Insp : movement of chest wall symmetrical, bruise (-)

Pal : crepitation (-), tenderness(-)

Per : sonor right = left, percussion pain (-)

Aus : Basic breath sound vesicular

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Abdomen

Insp : flat, hematoma (-), bruise (-),

muscular defense (-)Palp : smooth, Hepar/Lien no palpable

enlargement, tenderness on palpation (-)

Perc : Tympani, tenderness on percussion (-)Ausc : bowel sound (+) 6x/min

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Extremities

Upper Extremity :Bruise (-), cap. Refill time< 2, warm extremity,edema(-).

Lower Extremity :

Bruise (-), cap. Refill time< 2, warm extremity,edema(-).

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LOCALIZED STATUS

Regio Manus Dextra

Look : Wound (+), Active bleeding (+)

Feel : Crepitation (-)

Tenderness Pain (+)

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DIAGNOSIS

Fraktur Amputasi Digiti III

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TREATMENT

Wound Toilet

Hecting

Anti-Tetanus SerumMedication : Antibiotic

Analgetic

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