Patient List

No Identity Admission Diagnosis Treatment

to E.R.

1. Mr. Taufik/ 36 February Mild head injury + close Observation nausea

yo/ 1-14-15-25 fracture right clavicle and vomiting 6
26th 2015
hours
at 12.00
Arm sling

2.
Mr. February Close fracture tibia sinistra Circular casting
Harliansyah/ 26th 2015 at
20 yo/ 1-14-15- 12.00
27

3. February Vulnus laceratum a/r cruris Dressing wound

27th 2015 at sinistra Mefenamat acid 3x
Miss. 11.00 500 mg
Herlina/ 24 Cefadroxil 3 x 500
yo/ 1-14-16-17 mg
Hecting
1. Mr. Taufik/ 36 yo/ / 1-14-15-25 / February
26th 2015 at 12.00
 Chief Complain :
pain at right shoulder
 History :
4 hours before admission, when he was riding a
motorcycle with his nephew, helmet (+), he had
been hit a car beside them. His head and his right
hand fell to the asphalt, his head had wound with
bleeding and his right hand pain. History of
bleeding from mouth (-), nose (-), ear (-), vomiting
(-), seizure (-), He was brought Ulin hospital after
brought to health center Gambut
 General Status

A • Clear, snoring (-), gurgling (-)

• Clear, RR= 22 bpm, symmetric

B
respiratory movement

• BP : 130/90 mmHg
C • Pulse rate : 90 bpm, reguler, strong lifted,
CRT < 2 sec.

• GCS E4V5M6 (15), Round and

D symmetric pupils diameter (2mm/2m),
Light reflexes (+/+)
A -

M -

P -

L -

E Road
 Secondary survey

•Eye : Anemic conj. (-/-), icteric sclera (-/-)

•Mouth : Moist mucous membrane
Head/Neck •Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

• I : Symmetric respiratory movement, retraction (-)

Chest •
•
P : Symmetric VF
P : Sonor in all lung field
• A : Symmetric VBS, Rh (-/-), Wh (-/-)

• I : Wound (-), distension (-), hematoma (-)

Abdomen • A : Normal bowel sound

• P : H/L/M not palpable, tenderness (-), mass (-)
• P : Tympanic in all quadrants

Extremitie • Warm extremities, parese (-),

s • a/r right upper arm : swelling (+), pain (+)
Clinical Pictures
Local Status

 a/r right upper arm

L: swelling (-)
deformities (-)
F: pain (+) krepitasi (-)
M: limited rom due to
pain
X-Ray
 Working Diagnosis

Mild head injury + close fracture right clavicle

 Management
Observation nausea and vomiting 6 hours

Arm sling
 2. Mr. Harliansyah/20 yo/ 1-14-15-27/
February 27th 2015 at 12.00

 Chief Complain :
pain at left foot
 History :
4 hours before admission, when he was riding a
motorcycle with his uncl, helmet (+), he had been
hit a car beside them. His left foot had been hit a
car. His head fell to the asphalt, it makes wound.
History of bleeding from mouth (-), nose (-), ear (-
), vomiting (-), seizure (-), He was brought Ulin
hospital after brought to health center Gambut
 Primary Survey

A • Clear, snoring (-), gurgling (-)

• Clear, RR= 24 bpm, symmetric

B
respiratory movement, symmetric VBS

• BP : 130/70 mmHg
C • Pulse rate : 100 bpm, reguler, strong
lifted, CRT < 2 sec.

• GCS E4V5M6 (15), Round and

D symmetric pupils diameter (3mm/3m),
Light reflexes (+/+)
A • (-)

M • (-)

P • (-)

• 7 hours before
L admission

E • Road

Patient’s list
 Secondary survey

•Eye : Anemic conj. (-/-), icteric sclera (-/-)

Head/Nec •Mouth : Moist mucous membrane
k •Neck : JVP enhancement (-/-), lymphatic nodes
enlargement (-/-)

• I : Symmetric respiratory movement, retraction (-)

Chest •
•
P : Symmetric VF
P : Sonor in all lung field
• A : Symmetric VBS, Rh (-/-), Wh (-/-)

• I : Wound (-), distension (-), hematoma (-)

Abdomen • A : Normal bowel sound

• P : H/L/M not palpable, tenderness (-), mass (-)
• P : Tympanic in all quadrants

• Warm extremities, parese (-),

Extremitie • a/r cruris sinistra : swelling (+), pain (+)
s
Clinical Pictures
Status Localis

 a/r cruris sinistra

L: swelling (+)
deformities (-)
F: pain (+) krepitasi (+)
M: limited rom due to
pain
X-Ray
 Working Diagnosis

Close fracture tibia sinistra

 Management

Circular casting
 3. Miss. Herlina/24 yo/ February 27th 2015 at 11.00

• Chief Complain : Open wound at right foot

• History :
10 hours before admission patient was slipped when climb
down the fence. Distance from ground about 1 meter. Patient
felt with her right foot hit something, it makes open wound
with bleeding. Patient then brought to health center. Patient
then referred to Ulin General hospital for treatment.
 Primary Survey

A • Clear, snoring (-), gurgling (-)

• Clear, RR=28x/min, symmetric

B
respiratory movement

• BP: 120/70 mmHg, Pulse rate: 88 x/m

C
regular

• GCS E4V5M6, round and equal pupils

D diameter (3mm/3mm), light reflexes
(+/+),
A -

M -

P -

L -

E At home
 •Eye : anemic conjunctivae (-/-), icteric sclerae (-/-)
Head/Neck •Mouth : Moist mucous membrane
•Neck : increase of JVP (-) enlargement of nodes (-)

• I : symmetric respiratory movement, retraction (-),

• P : symmetric VP
Chest •
•
P : Sonor in all lung field
A : symmetric VBS, Rh (-/-), Wh (-/-)

• I : Flat, supple, hematoma (-), laceration (-)

• A : Normal bowel sound
Abdomen • P : H/L/M not palpable, tenderness (-),
• P : Tympanic in all quadrants

• Warm extremities, parese (-),

Extremities • a/r cruris dextra : swelling (-), pain (+), open wound (+)
Status Localis
• a/r cruris sinistra
L: swelling (-)
deformities (-)
F: pain (+) krepitasi (-)
M: limited rom due to
pain
 Working Diagnosis
Vulnus laceratum a/r cruris sinistra
 Management
Dressing wound
ATS
Mefenamat acid 3x 500 mg
Cefadroxil 3 x 500 mg
Hecting