Emergency Unit

Night Shift Report

March, 25
th
2014
Assistant:
Dr. Hendy S
Co-assistant:
Princessa S(chief)
Hizkia D
Ocha Poetra
Devi
Tiur
Melati Indriana
1. Ms. J (23 Years Old)
MR. 18.42.05.00
Mechanism of the Trauma
working accident
Injury of target organ
Palmaris manus sinistra
Symptoms and signs
Pain on palmaris manus sinistra
bleeding
Treatment Pre Hospital (Before UKIS ER)
-
PRIMARY SURVEY
Airway
Look : no obstruction
Listen : no extra breath sound (no gurgling, no snoring,
no stridor, no horseness)
Feel : there were warm air from both nose and mouth
Conclusion : CLEAR
Breathing
Inspection: bruise (-), chest wall movement symmetrical,
RR 21 x/min, hematoma ()
Palpation : crepitation (-)
Percussion: sonor right = left
Auscultation: Basic breath sound vesicular, rh -/-, wh -/-
Conclusion : CLEAR








Circulation
Warm extremities,
Pulse = 92 x/min
BP = 120/80 mmHg
Temp= 36.4
0
C
RR = 21 x/min
CRT <2
Conclusion : No Sign Of Shock
Disability
GCS 15 (E4M6V5) pupil isochoric 3/3 mm, centered,
Direct light reflex +/+ , indirect light reflex +/+
Exposure
Theres no life threatening wounds on regio manus sinistra


Secondary Survey

Chief complaint : pain on regio manus sinistra
Additional Complaint : bleeding

History of illness
A patient came accompanied with his
friends to UKIs E.R because of an
accident in the working place 1 hour
ago. He felt pain on the left hand
because get drilled. No vomitus,
bleeding on regio palmaris manus
sinistra, oedem on regio dorsum sinistra
(+).
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA +/+ , right sclera
hematoma (+)
Ear : normal, LCS (-), bleeding (-),
blood spot (-)
Neck : Bruise (-), hematoma (-)

1. Vulnus punctum on regio palmaris manus sinistra
size : 0,3 x 0.3 cm
Superior Extremities
Look : Vulnus punctum on regio palmaris
manus sinistra size : 0,3 x 0.3 cm, oedem
(+), hematoma (-), bleeding on (+)
rotation (-)
Feel : Warm, CRT <2, pain on palpation
(-), crepitation (-)
Movement : able to move gently
Motoric ++++/++++
Sensoric ++++/++++

Inferior Extremities
Look: edema (-), hematoma (-), rotation (-)
Feel: pain on palpation (-), crepitation (-)
Movement : able to move gently
sensoric ++++/++++
motoric ++++/++++

AMPLE
Allergy : -
Medication : -
Past Illness : -
Last Meal : -
Event : Working Accident
Working diagnose
Vulnus Punctum on regio palmaris pedis
sinistra
TREATMENT

Non Medicamentosa :
Cross Incisi
Debridement
Medicamentosa :
Sporetic 2 x 100mg
Acran 2 x 1
Ketesse 3 x 1
2. Ms. L (17 Years Old)
MR. 56.41.05.00
Mechanism of the Trauma
Traffic accident
Injury of target organ
Maxilla dextra, sclera dextra, and superior lip
Symptoms and signs
Pain on maxilla dextra, headache, and nausea
Treatment Pre Hospital (Before UKIS ER)
-
PRIMARY SURVEY
Airway
Look : no obstruction
Listen : no extra breath sound (no gurgling, no snoring,
no stridor, no horseness)
Feel : there were warm air from both nose and mouth
Conclusion : CLEAR
Breathing
Inspection: bruise (-), chest wall movement symmetrical,
RR x/min, hematoma ()
Palpation : crepitation (-)
Percussion: sonor right = left
Auscultation: Basic breath sound vesicular, rh -/-, wh -/-
Conclusion : CLEAR








Circulation
Warm extremities,
Pulse = x/min
BP = mmHg
Temp= 36.5
0
C
RR = x/min
CRT <2
Conclusion : No Sign Of Shock
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 : pain on the head and thorax
Additional Complaint: headache, nausea

History of illness
A patient came accompanied with train
officer to UKIs E.R because of an
accident in the train station at twenty
minutes ago. She was fainted for few
minutes. The patient doesnt know how
was the accident happening. She felt
pain on the right cheek, headache, and
nausea. Projectile vomit (-), massive
bleeding (-), edema (-).
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA +/+ , right sclera
hematoma (+)
Ear : normal, LCS (-), bleeding (-), blood spot (-)
Neck : Bruise (-), hematoma (-)

1. Vulnus excoriation on regio
maxillofacial (size : 7 x 4 cm),
superior (size : 0.8 x 0.3 cm)
2. Edema on the regio maxillofacial

Superior Extremities
Look : Edema (-), hematoma (-), massive
bleeding (-) rotation (-)
Feel : Warm, CRT <2, pain on palpation
(-), crepitation (-)
Movement : able to move gently
Motoric (++++)
Sensoric (++++)

Inferior Extremities
Look: edema (-), hematoma (-), rotation (-)
Feel: pain on palpation (-), crepitation (-)
Movement : able to move gently
sensoric (++++)
motoric (++++)

X-ray schedel
X-ray cervical

AMPLE
Allergy : -
Medication : -
Past Illness : -
Last Meal : rice and chicken at 7 am
Event : Traffic Accident
Working diagnose
Mild Head Injury + Vulnus excoriation with
edema on maxillofacial + vulnus ulceration
on superior lip + right sclera hematoma
TREATMENT

Non Medicamentosa :
Reposition, hospitalized
Medicamentosa :
RL + Ikaneuron 1 amp, Ergotika 2 amp
RL + Ketesse 3 amp