morport 09maret 2014

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Emergency Room

Morning ReportMarch, 9th 2014

3 patient trauma



1. Mrs. R ( 57 YO)

Mechanism of the Trauma

Fell from the motorcycle

Injury of target organ

laserated wound at supraorbital region dextra

Symptoms and signs

-

Treatment by: -



PRIMARY SURVEY

•

Airway : No snoring, No gargling, No StridorConclusion : CLEAR

• Breathing :

Insp : bruise -, chest wall movement symmetrical, RR

20 x/min, hematoma -Pal : vocal fremitus simetrical right and left,

crepitation -

Per : sonor right = left

Aus : Basic breath sound bronchial, rh -/-, wh -/-

Conclusion : No pneumothorax, no hemothorax

CLEAR



• Circulation

– warm extremities, Pulse = 80 bpm, Temp=

36,50C, capillary refill <2” Conclusion : No sign of shock

• Disability – GCS 15 (E4M6V5) pupil isochoric 3/3 mm,

centered,

– direct light reflex/indirect light reflex +/+

• Exposure

There is no life threatening wounds



AMPLE

• Allergy : -

• Medication : -

• Past Illness : -

• Last Meal : 15 minutes before

admittion

• Event : Fell from stairs



Secondary Survey

• Chief complaint : wound at head after fell

motorcycle accident

• Additional complaint : -



History of Illness

• Patient came with complaint wound on forehead

region. History of motorcycle accident. Faint

denied, vomits denied. Seizure denied. Patient

also complaint that she had pain on that wound.



General Examination

GC : Look moderately sick

Consciousness: E4M6V5 GCS 15 pupil

circular, isochoric 3mm/3mm, centered,

DLR +/+, ILR +/+,Vital sign

BP : 120/80 mmHg

HR : 82 b/m

RR : 20 b/m

T : 36,5°C



Localised status

Head to toe :

L : Vulnus Laseratum regio supraorbita

dextra , dasar soft tissue size 3 x 1 x 0,5

cmF : Pain (-)

M : -



Thorax :Insp : bruise (-), movement of chest wall

symmetrical

Pal : crepitation (-), palpation pain (-) Per : sonor right = left, percussion pain (-)

Aus : Basic breath sound vesiculer

right=left



Abdomen :

Ins : flat, skin colour was the same.

Aus : bowel sound 5x/minute

Pal : pain on palpation (-), defence muscular (-)

Per : tympani, percussion pain (-)

Extremity :

Warm extremities, cap refill < 2”, edema (-).



Diagnosis

Vulnus laseratum regio supra orbita

dextra



Treatment

•

Non MedicamentosaWound Toilet

Hecting

ATSOutpatient

• Medicamentosa

Cefixime 2 x 100 mg

Ketesse 3 x 1 tab

Ranitidine 2 x 1 tab+



2. Mr. R ( 35 YO)


Fell from the motorcycle


Vulnus excoriation at right foot and left foot

Symptoms and signs

-

Transported by

Patient came with her family



PRIMARY SURVEY

• Airway : No snoring, No gargling, No Stridor

Conclusion : CLEAR

• Breathing :


20 x/min, hematoma -

Pal : vocal fremitus simetrical right and left,

crepitation -




CLEAR



• Circulation

– warm extremities, Pulse = 80 bpm, Temp= 36,50C,

capillary refill <2” Conclusion : No sign of shock


centered,


• Exposure




AMPLE

• Allergy : -

• Medication : -


• Last Meal : 15 minutes before

admittion

• Event : Fell from motorcycle



Secondary Survey

• Chief complaint : wound at right foot and

left foot after fell from motorcycle




History of Illness

• Patient came with complaint wound at right

foot and left foot. History of motorcycle

accident. Faint denied, vomits denied. Seizure

denied. Patient also complaint that he had painon that wound.



HEAD TO TOE

Head : Regio pedis dextra et sinistra

L :Vulnus excoriatum regio pedis dextra et

sinistra

F : Pain (-)M : -



Thorax :Insp : bruise (-), movement of chest wall

symmetrical

Pal : crepitation (-), palpation pain (-) Per : sonor right = left, percussion pain (-)

Aus : Basic breath sound bronchial

right=left, wh-/-, rh-/-.



Abdomen :

Ins : flat, bruise (-), muscular defense (-)

Aus : bowel sound (+) 5x/min

Pal : tenderness (-)


Extremity :




Clinical foto



Working diagnose

Vulnus excoriatum regio pedis dextra et

sinistra



TREATMENT

• Non Medicamentosa :

Outpatient• Medicamentosa :

Ketesse 3 x 1 tab

Ranitidine 2 x 1 tab



3. Mr. H ( 43 YO)


wound at right hand and left hand


Vulnus excoriasi multiple regio manus dextra etsinistra

Symptoms and signs

-Transported by

Patient came with his friend



PRIMARY SURVEY

• Airway : No snoring, No gargling, No Stridor

Conclusion : CLEAR

• Breathing :


16 x/min, hematoma -

Pal : vocal fremitus simetrical right and left,

crepitation -




CLEAR



• Circulation

– warm extremities, Pulse = 82 bpm, Temp= 36,50C,

capillary refill <2” Conclusion : No sign of shock


centered,


• Exposure




AMPLE

• Allergy : -

• Medication : -


• Last Meal : 3 hours before admittion

• Event : -



Secondary Survey

• Chief complaint : wound at right hand and

left hand




History of Illness

Patient came to the hospital with complaint

wound at right hand and left hand. History of

trauma glass ± 2 hours before admission. Active

bleeding (-), numb (-), Active arm movement inall directions.



HEAD TO TOE

Head : Normocephali

Eyes : Pupil circular, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect

Light Reflex +/+

Ear : normal, LCS (-), blood (-)

Neck : Bruise (-), hematom (-)

Thorax :

Insp : bruise (-), movement of chest wall

symmetrical

Pal : crepitation (-), palpation pain (-)

Per : sonor right = left, percussion pain (-)

Aus : Basic breath sound bronchial right=left, wh-/-, rh-/-.



Abdomen :

Ins : flat, bruise (-), muscular defense (-)

Aus : bowel sound (+) 5x/min

Pal : tenderness (-)


Extremity :




Clinical foto



Working diagnose

Vulnus Excoriatum multiple regio manus

dextra et sinistra



TREATMENT

Non Medicamentosa :

Patient went home

• Medicamentosa :

Amoxilin tab 3 x 500 mg

Asam mefenamat tab 3 x 500 mg

Ranitidine tab 2 x 1 mg

morport 09maret 2014

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