Emergency Room

Morning Shift Report

March, 31st 2013

1. Mr. D (22 YO)

M : Falling from a motorcycle I : thoraks dextra, superior palpebra dextra S : Pain T : already to the clinic and was given medication Self protection (patient doesnt use helmet) Patient can talk coherently in long sentence

Primary Survey
Airway : Clear Breathing : Insp: bruise (-), chest wall movement symmetrical, RR 20 x/ min, hematoma (-) Pal: crepitation sub cutis (-) Per : sonor right = left Aus : Basic breath sound vesicular

 C = warm extremities, Pulse = 88bpm, BP 160/100 mmHg, Temp = 37C, capillary refill time <2 D = GCS E4M6V5, pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+ E = there is no life threatening wound

History of illness :
Patients come to the RSU UKI due to a fall from a motorcycle one day before coming to the hospital. Patient ride the motorcycle with speed 60 km/hour. Patient fall to the ground and the motorcycle handlebar hit on his chest first. Patient already treated to a clinic and was given medication. But patient feel pain on his chest. Head impact (-), abdominal impact (-) vomiting (-), nausea (-), unconsciousness (-), headache (-)

SECONDARY SURVEY
HEAD TO TOE
Eyes: pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+, hematoma (+/-) Ear: Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-) Thorax: Insp : bruise (-), movement of chest wall symmetrical Pal : crepitation sub cutis (-), tenderness (-) Per : sonor right = left Aus: Basic breath sound vesicular

 Abdomen : Ins: flat, bruise (-) Aus: bowel sound (+) 9x/min Pal: Supel, tenderness (-), muscular defense (-) Per: tympani Extremity: Warm extremities, cap. refill time < 2, edema (-)

Localized Status
Regio thoraks dextra
Insp : bruise (-), movement of chest wall symmetrical Pal : crepitation sub cutis (-), tenderness (-) Per : sonor right = left Aus: Basic breath sound vesicular

Diagnosis
Blunt thoracic trauma

TREATMENT

MM/ : 1. ketesse 2 x 1 2. ranitidin 2 x 1 3. becom c 1x 1

Tn. A R (32 YO)

M: exposed stones I : head (regio parietal) S : Pain in the wound T : patients was given treatment in clinic (wound toilet, betadine, and verban) Self protection (use gloves)

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Primary Survey
Airway : Clear Breathing : Insp: bruise (-), chest wall movement symmetrical, RR 18 x/ min, hematoma (-) Pal: crepitation sub cutis (-) Per : sonor right = left Aus : Basic breath sound vesicular

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 C = warm extremities, Pulse = 80 bpm D = GCS E4M6V5, pupil isochors 3mm/3mm, centered, direct light reflex/ indirect light reflex +/+ E = there is no life threatening wound

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Secondary Survey
Chief complaint: pain in the wound Additional complaint: -

History of illness:
Patients come to the hospital with complaints of injuries to the head (in the parietal) because of a thrown stone since one hour before entering the hospital. Patient was walking around railroad crossing and exposed stones throw from the train that was passing, the stone like a tennis balls, the patient was immediately taken to a clinic near railway crossing and then stopped the bleeding. Patient then came to RS UKI to further therapy Head impact (+), chest impact (), abdominal impact (-), vomiting (-), unconsciousness (), active bleeding (+).

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SECONDARY SURVEY
HEAD TO TOE
Eyes: pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+ Ear: Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-) Thorax: Insp : bruise (-), movement of chest wall symmetrical Pal : crepitation sub cutis (-), tenderness (-) Per : sonor right = left Aus: Basic breath sound vesicular
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 Abdomen: Ins: flat, bruise (-) Aus: bowel sound (+) 6 x/min Pal: Supel, tenderness (-), muscular defense (-) Per: tympani Extremity: Warm extremities, cap. refill time < 2, edema (-)
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Localized Status
Regio Parietalis L : bleeding (+), vulnus laceratum 3x 0,5x 0,5 cm F : crepitation (-)

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Diagnosis
Vulnus laceratum regio parietalis

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TREATMENT
Wound toilet Hecting MM : ketesse

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Emergency Room

Morning Shift Report

March ,31st 2013

1 non-trauma patient

Mr. M ( 36 YO)
Chief complain : - right pelvic pain

Additional complain : - vomitting

History of illness :
Patient came to IGD RSU UKI with complaints of right pelvic pain since two hours before coming to the hospital. The pain was radiating to the right lower abdomen. This complaint is felt when the patient begins to micturition. Patients could micturition but a few minutes later when the patient wants to micturition, the patient should straining and finally just let out a little micturition. History of pain during micturition (-), history of weak micturition (-)

General Examination GC: Look moderate illness E4M6V5 compos mentis BP: 150/90mmHg HR: 80 x/m RR: 24 x/m T : 36,3C

Localized examination :
Head: normocephali Eyes: CA -/-, SI -/-, pupil isochor 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex +/+ Ear : normal Neck : Lymph node enlargement (-)

Thorax : Insp : bruise (-), movement of chest wall symmetrical Pal : crepitation (-), pain on palpation (-) Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer

Abdomen : Ins: flat, bruise (-), muscular defense (-) Aus: bowel sound (+) 3x/min Pal: right lower abdominal tenderness (+) Per: timpani, percussion pain (-), percussion pain CVA +/- , ballotement -/-

 Suprapubic Region : circumcision (+) phimosis (-) mass (-) Rectal Touche : Insp: fistula ani (-), fisura ani (-), mass (-), hiperemis (-), faeces(-), blood(-)

 Rectal touche : Pal: TSA (+), ampulla recti not collapse, prostate size laterolateral 2cm-2cm, nodule(-), upper pole palpable, mass (-), tenderness (-)

Extremity : warm extremities, cap. refill < 2, edema (-)

Diagnose
Cholic ureter ec susp. ureterolithiasis dd: nefrolithiasis

Treatment
Pro Hospitalized Diet : normal IVFD : I RL MM : - ceftriaxone 2x1 gr (skin test) - ranitidin 2x1 amp - buscopan drip

1. An D(8 YO)
M : scalded by hot water I : Regio aksila and scapula dextra S : pain on the wound T : immediately washed down with cold water and given ointment bioplacenton, then taken to the clinic and was given antibiotics, analgesics and ointments bioplacenton.

 Airway : Clear (No gargling, No Stridor, No Snooring) Conclusion : clear Breathing : Insp: bruise -, chest wall movement symmetrical, RR 24 x/min Pal : crepitation Per : sonor right = left Aus : Basic breath sound vesiculer Conclusion : No pneumothorax, no hematothorax

 C = warm extremities, Pulse = 96bpm , BP 120/80mmHg, Temp= 36,50C, capillary refill <2 Conclusion : No sign of shock D =GCS E4M6V5, pupil isochoric 3/3 mm, centered, direct light reflex/indirect light reflex +/+ Conclusion : Sign of mild head injury E = thorax : bruise -, abdomen: bruise -, thighs: bruises -, pelvic deformity
Conclusion: no life threatening wounds

Secondary Survey
Chief complaint : pain on the wound Additional complaint : no additional complaint

History of illness (auto anamnesis) : 1 hour before admissions, patient got a single accident while she scalded by hot water. the affected body part is the right chest and back right. At that time the patient's grandmother had just taken the hot water from the dispenser and the patient suddenly hit her grandmother was so affected by the hot flush. Sometime after exposure to hot water is instantly the patient's skin was flushed to blister and peel. Patients immediately washed down with cold water and topical ointments bioplacenton then brought to the clinic and given antibiotics, analgesics and bioplacenton. No visible signs of shock

AMPLE
Allergy : Medication : Bioplacenton Past Illness : Last Meal : Event : scalded by hot water

HEAD TO TOE Head: Bruise (-),oedem (-), Hematom (-), blood ( -), swelling (-) Eyes: Pupil circular, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex +/+, Ear : Bruise (-), hematom (-) Neck : Bruise (-), hematom (-)

Thorax : Insp : bruise (-), movement of chest wall symmetrical, Pal : crepitation (-), pain on palpation (-) Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer

Abdomen : Ins: flat, hematom (-), bruise (-), muscular defense (-), Aus: bowel sound (+) 4x/min Pal: tenderness (-) Per: Percusion tenderness (-)

Extremity : warm extremities, cap. refill < 2, edema (-)

Localized status
Regio aksila dextra
L: burns skin with epidermal tissue disappears, eritema +,bulla+ F: palpation pain +

Regio scapula dextra

L: burns skin with epidermal tissue disappears, eritema +, bulla + F: palpation pain +

Regio Photo

Primary Survey
Airway : Clear (No gargling, No Stridor, No Snooring) Conclusion : clear Breathing : Insp: bruise -, chest wall movement symmetrical, RR 24 x/min Pal : crepitation Per : sonor right = left Aus : Basic breath sound vesiculer Conclusion : No pneumothorax, no hematothorax

 C = warm extremities, Pulse = 96bpm , BP 120/80mmHg, Temp= 36,50C, capillary refill <2 Conclusion : No sign of shock D =GCS E4M6V5, pupil isochoric 3/3 mm, centered, direct light reflex/indirect light reflex +/+ Conclusion : Sign of mild head injury E = thorax : bruise -, abdomen: bruise -, thighs: bruises -, pelvic deformity Conclusion: no life threatening wounds

Diagnosa
Scalding burn grade IIA 10%, regio aksila dextra and scapula dextra.

TREATMENT
IV line (Rl ) Wound toilet Mm / ( analgetic, antibiotic, ATS) Observation on vital sign and wound care treatment.