Morpot Yg Stress

7/25/2019 Morpot Yg Stress

1/51

Emergency Room

Morning ShiftReport

March, 19th2013


2/51

1.Mr.J(25 month)

PRIMARY SURVEY

M : fell from motorcycle

I : head,left shoulder,right knee

S : pain

T : -Self protection:

Patient can talk coherently

Patient was brought by his family with car to UIhospital


3/51

Primary Sur!ey

"irway : clear

#reathing :

Insp : chest wall mo!ement

symmetrical, $$ %% &'min,bruise (-)

Pal : crepitation -

Per : sonor right * left"us : #asic breath sound !esiculer


4/51

+ * cold acral, Pulse * 'm,capillary re.ll /%0

1* 2+S 34M567, pupil isochoric 4'4

mm, centered, direct lightre8e&'indirect light re8e& 9'9 ,lateraliation (-)

3 * There;s no life threateningwound


5/51

History of illness (allo

anamnesis) :

Patient came to 3mergency $oom UI hospitalafter fell down from motorcycle < 4 minutes beforeadmittance to hospital= the patient was onmotorcycle with speed < >km'hour= Patient a!oidthe car then fell to the left side and his left shoulderhit the road=his right knee was hit the road=patient

wearing full face helm= ?ead impact (9), chestimpact (-), unconciousness (9),amnesia(9), nausea(-), !omitus (-)=


6/51

"MP@3

"llergy : -

Medication : -

Past Illness : -

@ast Meal : < hours before admittance

3!ent : motorcycleaccident


7/51

HEA !" !"E

2eneral 3&amination

2+S : @ook moderate illness3AM567

#P : '> mm?g

?$ : B &'m

$$ :%% & 'mT : 45,7 -+

?ead : #ruise -

3yes : Pupil circular, isochoric 4mm'4mm,centered, 1irect @ight $e8e& 9'9,

Indirect @ight $e8e& 9'9


8/51

3ar : otorhhea (-)

Ceck : #ruise (-)

Thora&Insp : mo!ement of chest wall symmetrical,

bruise (-)

Pal : crepitation (-)



9/51

"bdomen

Ins : 8at,bruise (-)

Pal : tenderness (-)

Per : Percusion tenderness (-),Tympani

"us : bowel sound (9) 4&'min

3&tremity :warm acral, cap= re.ll / %0


10/51

@D+"@IE31 ST"TUS

Regio facialis

@ook :multiple !ulnus e&coriasi &cm, %&% cm,swollen (-), hematom (-), acti!e bleeding (-)

Feel : tenderness (9), crepitation (-)

Regio gen# $e%tra

@ook : !ulnus e&coariasi, & cm,swollen(-),haematom (-),acti!e bleeding (-)

Feel : tenderness (9),crepitation (-)

Mo!ement: acti!e and passi!e mo!ement isunlimited


11/51


12/51


13/51

1I"2CDSIS

Mild head inGury 9 edema cerebri


14/51

T$3"TM3CT

- D% face mask B lpm

- I6F1 : $@

- Hound toiletMm'

Ikaneuron &

3rgotika %& etorolac &

$anitidine %&

Patient was sent home


15/51

2. Mrs. H (27 YO)

PRIMARY SURVEY

M : felt down from motorcycle

I : chin, right knee

S :pain on inGury

T : -Self protection:


Patient was brought by her friend with car to UIhospital


16/51

Primary Sur!ey

"irway : clear

#reathing :


symmetrical, $$ % &'min,bruise (-), hematoma (-)

Pal : crepitation -

Per : sonor right * left "us : #asic breath sound !esiculer

right*left


17/51

+ * warm acral, Pulse * BA'm,capillary re.ll /%0

1* 2+S 3AM567, pupil isochoric 4'4

mm, centered, direct lightre8e&'indirect light re8e& 9'9 ,lateraliation (-)



18/51

History of illness (allo

anamnesis) :

Patient came to 3mergency $oom UI hospitalafter felt down from motorcycle < 7 minutes beforeadmittance to hospital= The patient hit the cone,with speed Akm'hour and used helmet= The chinpatient hit to the soil , the right knee hit to the soil =

The patient complaint hard to speak=?ead impact

(9), chest impact (-) unconciousness (-), nausea (-),!omitus (-)=


19/51


20/51

HEA !" !"E

2eneral 3&amination

2+S : @ook moderate illness3AM567

#P : %'B mm?g

?$ : BA &'m

$$ :% & 'mT : 45,5 -+

?ead : #ruise - , oedem - , ?aematom - , blood -

3yes : Pupil circular, isochoric 4mm'4mm,

centered, 1irect @ight $e8e& 9'9,Indirect @ight $e8e& 9'9


21/51

3ar : otorhhea (-)

Ceck : #ruise (-), haematom (-)


bruise (-)


Per : sonor right * left"us : #asic breath sound !esiculer right * left


22/51

"bdomen

Ins : 8at, hematom (-), bruise (-),

muscular defense (-)


Per : Percusion tenderness (-),

Tympani

"us : bowel sound (9) 5&'min

3&tremity :

warm acral, cap= re.ll / %0


23/51


24/51

@D+"@IE31 ST"TUS

Regio s#&man$ilaris@ook : !ulnus laceratum A&&,7 cm,

deformity(-), swollen (-), hematom (-), acti!ebleeding (-)

Feel : tenderness (9), crepitation (-)Regio gen# $e%tra

@ook : !ulnus ekskoriasi 4&% cm, deformity(-),swollen (-), hematom (-), acti!e bleeding (-)

Feel : tenderness (9), crepitation (-)


25/51

1I"2CDSIS

6ulnus laceratum regio sub

mentalis


26/51


27/51

3. R child ( 10 yo )

PRIMARY SURVEY

M : motorcycle accident

I : head, left arm, right and left knee

S : pain on inGuryT : antiseptic

Self protection: use glo!es


Patient was brought by car to UI hospital


28/51

Primary Sur!ey

"irway : clear

#reathing :


symmetrical, $$ %5 &'min,bruise (-), hematoma (-)

Pal : crepitation -

Per : sonor right * left"us : #asic breath sound !esiculer=


29/51


30/51

History of illness (a#to

anamnesis) :

patient came to Emergency room UKI hospital because was hit bymotorcycle with speed 80km/hour. Patient fell with prone

position.ead impact (9), chest impact (-)unconciousness (-), nausea (-), !omitus (-),headache (9)=


31/51

"MP@3

"llergy : -

Medication : -

Past Illness : -

@ast Meal : < % hours before admittance

3!ent : motorcycleaccident


32/51


33/51

3ar : otorhhea (-)Ceck : #ruise (-)

Thora&Insp : mo!ement of chest wall symmetrical,bruise (-)




34/51

"bdomen




"us : bowel sound (9) A&'min



35/51

@D+"@IE31 ST"TUS

Regio frontalis $e%tra et sinistra

@ook : !ulnus ekskoriasi 7&4 cm= bruise(-),swollen (-),"cti!e bleeding,(-)

Feel : tenderness (9)

Regio!emporoparietal $e%tra et sinistra

@ook : bruise (-)

Feel : tenderness (9),crepitation (-)

Regio ante&rachii sinistra

@ook : !ulnus ekskoriasi,A&4 cm, bruise (9),acti!ebleeding (-)


Mo!ement : acti!e and passi!e mo!ement was unlimited


36/51


37/51


38/51

1iagnosis

Mild ?ead inGury


39/51

T$3"TM3CT

-Hound toilet

-Paracetamol 4&


40/51

3. Mr.E( 35 yo )

PRIMARY SURVEY

M : car accident

I : face

S : nose bleedingT :

Self protection: use glo!es


Patient was brought by car to UI hospital


41/51

Primary Sur!ey

"irway : clear

#reathing :


symmetrical, $$ % &'min,bruise (-)

Pal : crepitation -

Per : sonor right * left"us : #asic breath sound !esiculer=


42/51

+irculation : warm acral, Pulse *B%'m , capillary re.ll /%0

1 * 2+S 3AM567, pupil isochoric4'4 mm, centered, direct lightre8e&'indirect light re8e& 9'9 ,lateraliation (-)



43/51

History of illness (a#to

anamnesis) :

< 4 minutes before patient came to Emergency room UKIhospital!patient had car accident with speed "0km/hour. Patient

was sleepy and hit the other car in front of his car.ead impact(9), chest impact (-) unconciousness (-), nausea (-),!omitus (-), headache (-)=


44/51

"MP@3

"llergy : -

Medication : -

Past Illness : -

@ast Meal : < 4 hours before admittance

3!ent : car accident


45/51

HEA !" !"E

2eneral 3&amination

2+S : @ook moderete illness

3AM567

#P : 'B mm?g

?$ : B%'m

$$ : %'mT :45,7 +

?ead : #ruise (-)

3yes : Pupil circular, isochoric 4mm'4mm,

centered, 1irect @ight $e8e& 9'9,Indirect @ight $e8e& 9'9


46/51

3ar : otorhhea (-)Ceck : #ruise (-)


bruise (-)




47/51

"bdomen




"us : bowel sound (9) A&'min



48/51

@D+"@IE31 ST"TUS

Regio nasal

@ook : swollen (9),hematom(-)acti!e bleeding(-)



49/51


50/51

1iagnosis

Mild ?ead inGury


51/51

T$3"TM3CT

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Morpot Yg Stress

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