morpot13

M AY, 1 3 T H 2 0 1 1

Emergency Room

Night Shift Report

1 patient trauma

1. child A (1 1/2 YO)PRIMARY SURVEY

Self protection (gloves) Collar neck Patient was brought by policeman friend because motorcyle accident Airway : ClearBreathing :

Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on posteriolateral sinistra proximately at costae 6

Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae 5

Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/- , rh-/+

C = warm extremities, Pulse = 80 x/min , BP = 120/80 mmHg,Temp = 36,5°c, capillary refill < 2”

D = GCS 15 – E4V5M6, pupil isochoric 3 mm / 3 mm, direct light reflex/indirect light reflex +/+, lateralization (-)

E = There’s no life threatening wound

Secondary Survey1. Mr. IN (15 YO)

Chief complaint : pain at left foreheadAdditional complaint : pain at left chest when the patient

was breathing

SECONDARY SURVEY

History of illness : ±30 minutes before admittated to the hospital, the patient was

riding the motorcycle with estimated speed 40 km/h and then she was hit the busway separator. Suddenly she was fall from the motorcycle and patient full-faced helm was off from her head. Her left side (head and chest) was hit the asphalt. After fall from the motorcycle patient was unconscious 1 minute, after that patient woke up and then she unconscious again in less 1 minute. Patient complaining about the pain in her left temples and left chest, amnesia retrogade (+), nausea (-), vomiting (-), headache (-). Patient was taken to the hospital by police man after she woke up again.

AMPLE

Allergy : -Medication : -Past Illness : -Last Meal : 3 h before an accidentEvent : motorcycle Accident

HEAD TO TOE

General ExaminationGC : Look mild illness

E4V5M6 compos mentisBP : 120/80mmHgHR : 80x/mRR : 20x/mT : 36,5°CHead : Bruise -, Hematom -, tumor -, blood -Nose : normal, blood -, LCS -Eyes : Pupil round, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect Light Reflex +/+

Ear : normal, LCS -, blood -Neck : Bruise (-), hematom (-), nn.ll no

palpable enlarge

Thorax Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on

posteriolateral sinistra proximately at costae 6 Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae

5 Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/, rh-/+

AbdomenIns : flat, hematom (-), bruise (-), defence

muscular (-)Pal : tenderness (-) Per : Percusion tenderness (-), TympaniAus : bowel sound + 4x/m

Ekstremitascap. refill < 2”, edema (-), warm extremity,excoriasi regio

right elbow, dorsum pedis dextra.

Localized status

Regio frontotemporal L : vulnus

laceratum size o,5x0,5 cm bruise (-), oedem (+), hematome (+), active bleeding (-), passive bleeding (+),

F :tenderness (+), crepitation (-)

M : crepitation -

Infra orbita L : excoriasi 2x2

cm bruise (-), oedem (-), hematome (-), active bleeding (-), passive bleeding (-),

F :tenderness (+), crepitation (-)

M : crepitation -

DIAGNOSA

moderate head injury + oedem cerebri + contusio thorax

Foto x-ray

CT-scan

CT-scan

TREATMENT

HospitalizedO2 nasal kanul 3 lpm IVFD : - MM/ : antibiotic

antiemeticanalgetichaemostatic

3. Mr. S (60 YO)

Chief complaint : bleeding from the nose and mouth

Additional complaint : pain in the right shoulder

PRIMARY SURVEY

Self protection (gloves) Collar neck Patient was brought by policeman because motorcyle accident

Airway : ClearBreathing :

Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) Pal : crepitation (-), pain on palpation (-) Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/- , rh-/-

C = warm extremities, pulse = 78 x/min , BP = 140/100 mmHg, temp = 36,5°c, capillary refill < 2”

D = GCS 15 – E4V5M6, pupil isochoric dificult to asses, direct light reflex/indirect light reflex +/+, lateralization (-)

E = There’s no life threatening wound

Secondary survey

History;one half hour before entering the hospital the

patient was driving a motor with a speed of 40 km / h, and then plunged the hole and was thrown approximately one meter. Patients using the half-faced helmet, but the helmet came off and his face hit the asphalt. vomiting + (contains 10 cc of blood), nausea -, fainting -, collision chest +, + the head clash, collision abdominal -.

AMPLE

Allergy : -Medication : -Past illness : -Last meal : 9 h before accidentEven : traffic accident

Head to toe

General ExaminationGC : Look moderate illness

E4V5M6 compos mentisBP : 140/100mmHgHR : 78x/mRR : 20x/mT : 36,5°CHead : Bruise +, Hematom +, tumor -, blood +Nose : normal, blood -, LCS -Eyes : Pupil round, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect Light Reflex +/+

Ear : normal, LCS -, blood -Neck : Bruise (-), hematom (-), nn.ll no palpable

enlarge

Thorax Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on

posteriolateral sinistra proximately at costae 6 Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae 5 Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/, rh-/+

AbdomenIns : flat, hematom (-), bruise (-), defence

muscular (-)Pal : tenderness (-) Per : Percusion tenderness (-), TympaniAus : bowel sound + 4x/m

Ekstremitascap. refill < 2”, edema (-), warm extremity,excoriasi regio

right elbow, dorsum pedis dextra.

Localized status

Regio Orbitalis Dextra L : oedem (+), hematome (+), active bleeding (-),

passive bleeding (+), F : tenderness (+), crepitation (-) M :

Regio zygoma Dextra L : excoriasi 2x2 cm bruise (-), oedem (-), hematome

(-), active bleeding (-), passive bleeding (-), F : tenderness (+), crepitation (-) M : crepitation -

Regio frontalis dextra L : excoriasi 6x2 cm the base is soft tissue, oedem

(-), hematome (-), active bleeding (-), passive bleeding (+),

F : tenderness (-), crepitation (-) M : crepitation –

Regio nasalis L : bleeding from the nose, active bleeding (+),

passive bleeding (-) F : tenderness (-), crepitation (-) M : crepitation –

Regio oris L : blood +, active bleeding (+), passive bleeding

(-) F : tenderness (-), crepitation (-)

diagnosa

mild head injury

Thorax Foto