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8/13/2019 morpot 1.ppt
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Emergency Room
Morning Shift ReportMay , 31st 2013
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Mr. G ( 25 YO)
M : motor cycle accident
I : regio dorso manus dextra and sinistra
S : vulnus eksoriasi et dorso manus dextra and
sinistra, patela dextra
T : -
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Primary Survey Airway : Clear Breathing :
Insp : bruise (-), chest wall movement
symmetrical, RR 18 x/ min, hematoma (-) Pal : crepitation sub cutis (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right = left
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C = warm extremities, Pulse = 88bpm, BP 110/70 mmHg,
capillary refill time
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History of illness :
Patient came to the RSU UKI with police because the
patient had a traffic accident. The patient fell down
from his motor cycle with the left arm as a . After he
fell there was no active bleeding, no loss of
consciousness, no vomitting, theres no head injury.
Patient can talk coherently in long sentence and walkby himself to the hospital. Patient already went to the
clinic and has been given medication to heal his
headache.
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HEAD TO TOE
Eyes : pupil isochors 3mm/3 mm, centered, direct light
reflex/ indirect light reflex +/+
Ear : Bruise (-), hematoma (-)
Neck : Bruise (-), hematoma (-)
Thorax :
Insp : bruise (-), movement of chest wall symmetrical
Pal : crepitation (-), tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular right = left
SECONDARY SURVEY
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Abdomen :
Ins : flat, bruise (-)
Aus : bowel sound (+) 6x/min
Pal : Supel, tenderness (-), muscular
defense (-)
Per : tympani
Extremity:
Warm extremities, cap. refill time < 2,
edema (-)
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Localized StatusRegio Manus Dextra
Insp : bruise (+), active bleeding (-)
Pal : crepitation (-), tenderness (-)
Move : can palmar flexion, dorso flexion, ulnar
flexion, radier
Regio Manus Sinistra Insp : bruise (+), active bleeding (-), oedem (+)
Pal : crepitation (-), tenderness (+)
Move : cant palmar flexion, dorso flexion, ulnar
flexion, radier
Regio Genu Dextra Insp : bruise (+), active bleeding (-)
Pal : crepitation (-), tenderness (-)
Move : can palmar flexion, dorso flexion, ulnar
flexion, radier
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Diagnosis
Fr. Os radius sinistra intra artikular tertutup
tanpa gangguan NVD
Vulnus Eksoriasis dorso manus dextra-sinistra, dan patela dextra
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TREATMENT Sporetik 2x100 mg
Analgetik 3x1
Oscal 2x1 Tab