No Identity Admission to ER Diagnose Treatment

01 Mrs. Noraina / 52 y.o 2017 - Mild head injury GCS 15 IVFD RL 20 tpm
- fracture linier angulus Inj. ceftriaxone 2x1 gram
mandibula sinistra Inj. Ketorolac 2x30 mg
Inj. Ranitidine 2x50 mg
Inj. ATS

Co to ….
Advice:
No Identity Admission to ER Diagnose Treatment

02 Ilman Nafiah/17 y.o 2017 -Combustion 1% grade II at - Aspiration of bula

regio dorsum pedis sinistra - Wound management

Co to plastic surgery
Advice:
- Debridement
- Control to polyclinic
Mrs. Noraina/52 Y.O

Chief Complain :
Hard to open the mouth

History of Current Disease:

Patient hardly opened her mouth since 30 minutes before admission, after patient had a
traffic accident. Patient rode a motorcycle with her son and then she crashed a tree. She
forgot how the mechanism of the event happened.
 Primary Survey

– Airway: clear without C-spine control

– Breath: RR 20x/m, regular, wh (-/-), rh (-/-), spO2: 98%
w.o O2
– Circulation: N: 88x/m, BP: 140/100
– Disability: GCS 15, Light reflex (+/sde), BH (-/+), BS (-/-),
BR (-/+), BO (-/-)
 • Head : normal

Physical Diagnostic Head

• Eye : Anemic conj. (-/sde), icteric sclera (-/sde), isocor (3mm/sde),
racoon eyes (-/+), edema (-/+), hematom periorbita inferior (-/+)
• Mouth : Moist mucous membrane
• Neck : Increased level of JVP (-)

• I : Symmetric respiratory movement, no retraction

Thorax • P : Symmetric VF
• P : Sonor at all lung fields
• A : Symmetric VBS, no rhonchi , no wheezing

• I : Distension (-)

Abdomen • A : Bowel sound (+) normal

• P : tenderness (-)
• P : tymphani (+)

Extremity • Warm extremities (+)

• Open wound of the right forearm
Local status

Regio mandibula sinistra

– Look: vulnus laceratum 1x1 cm,
active bleeding (-), edema (+),
malocclusion (+)
– Feel: crepitation (+), tenderness (+),
swelling (+)
– Move: limited due to pain, open
mouth for one finger
 Skull
AP/LAT X-ray
2017
 Diagnosis

Mild head injury GCS 15 + fracture linier

angulus mandibula sinistra
 MANAGEMENT

– IVFD RL 20 tpm
– Inj. ceftriaxone 2x1 gram
– Inj. Ketorolac 2x30 mg
– Inj. Ranitidine 2x50 mg
– Inj. ATS

– Co to ….
– Advice:
Ilman Nafiah/17 Y.O

Chief Complain :
Burn wound

History of Current Disease:

Patient complained of burn wound since 4,5 hours before admission. Patient forgot to turn
off the stove when he cooked a fried egg, and then the flame got into the pan. His brother
took the pan and accidently hot oil in there felt to patient’s left leg. Patient was carried to
public health center Gambut and his wound has been dressing there. Patient then refered to
the Hospital.
 Primary Survey

– Airway: clear without C-spine control – A: -

– Breath: RR 22x/m, regular, wh (-/-), – M: -

rh (-/-), spO2: 98% w.o O2 – P: -
– Circulation: N: 98x/m, BP: 120/90 – L: 4.5 hours before admission
– Disability: GCS 15, Light reflex (+/+), – E: in the kitchen
BH (-/-), BS (-/-), BR (-/-), BO (-/-)
 • Head : Normal
Physical Diagnostic Head • Eye : Anemic conj. (-/-), icteric sclera (-/-), isocor (3mm/3mm)
• Mouth : Moist mucous membrane
• Neck : Increased level of JVP (-)

• I : Symmetric respiratory movement, no retraction

Thorax • P : Symmetric VF
• P : Sonor at all lung fields
• A : Symmetric VBS, no rhonchi , no wheezing

• I : Distension (-)

Abdomen • A : Bowel sound (+) normal

• P : tenderness (-)
• P : tymphani (+)

Extremity • Warm extremities (+)

Cinical photos

Local status at dorsum pedis sinistra

– Bula 10 cm x 10 cm, intact, the side is
darker
– Combustion 1% grade II
 Diagnosis

-Combustion 1% grade II at regio dorsum

pedis sinistra
 MANAGEMENT

– Aspiration of bula
- Wound management

Co to plastic surgery
Advice:
- Debridement
- Control to polyclinic
Clinical Photo after debridement
THANKS