Morpot Alex

7/29/2019 Morpot Alex

1/49

Emergency Room

Morning Shift ReportMarch, 31st 2013


2/49

1. Mr. D (22 YO)

M : Falling from a motorcycle

I : thoraks dextra, superior palpebra dextra

S : Pain

T : already to the clinic and was given medication

Self protection (patient doesnt use helmet)

Patient can talk coherently in long sentence


3/49

Primary Survey

Airway : Clear

Breathing :

Insp: bruise (-), chest wall movement symmetrical,

RR 20 x/ min, hematoma (-)

Pal: crepitation sub cutis (-)

Per : sonor right = left

Aus : Basic breath sound vesicular


4/49

C = warm extremities, Pulse = 88bpm, BP 160/100 mmHg,

Temp = 37C, capillary refill time


5/49

History of illness :Patients come to the RSU UKI due to a fall from a

motorcycle one day before coming to the hospital.

Patient ride the motorcycle with speed 60 km/hour.

Patient fall to the ground and the motorcycle

handlebar hit on his chest first. Patient already treatedto a clinic and was given medication. But patient feel

pain on his chest. Head impact (-), abdominal impact (-)

vomiting (-), nausea (-), unconsciousness (-), headache

(-)


6/49

HEAD TO TOE

Eyes : pupil isochors 3mm/3 mm, centered, direct light reflex/

indirect light reflex +/+, hematoma (+/-)

Ear: Bruise (-), hematoma (-)

Neck : Bruise (-), hematoma (-)

Thorax :

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

Pal : crepitation sub cutis (-), tenderness (-)


Aus: Basic breath sound vesicular

SECONDARY SURVEY


7/49

Abdomen :

Ins : flat, bruise (-)

Aus : bowel sound (+) 9x/min

Pal : Supel, tenderness (-), musculardefense (-)

Per : tympani

Extremity:Warm extremities, cap. refill time < 2,

edema (-)


8/49

Localized Status

Regio thoraks dextra Insp : bruise (-), movement of chest wall

symmetrical





9/49


10/49

Diagnosis

Blunt thoracic trauma


11/49

TREATMENT

MM/ : 1. ketesse 2 x 1

2. ranitidin 2 x 13. becom c 1x 1


12/49

12

Tn. A R (32 YO)

M: exposed stones

I : head (regio parietal)

S : Pain in the woundT : patients was given treatment in clinic

(wound toilet, betadine, and verban)

Self protection (use gloves)


13/49

13

Primary Survey

Airway : Clear

Breathing :

Insp : bruise (-), chest wall movement symmetrical,

RR 18 x/ min, hematoma (-) Pal : crepitation sub cutis (-)


Aus : Basic breath sound vesicular


14/49

14

C = warm extremities, Pulse = 80 bpm D = GCS E4M6V5, pupil isochors 3mm/3mm,

centered, direct light reflex/ indirect light reflex

+/+

E = there is no life threatening wound


15/49

Secondary Survey

Chief complaint : pain in the wound

Additional complaint : -


16/49

16

History of illness:Patients come to the hospital with complaints of

injuries to the head (in the parietal) because of athrown stone since one hour before entering thehospital. Patient was walking around railroad crossingand exposed stones throw from the train that waspassing, the stone like a tennis balls, the patient was

immediately taken to a clinic near railway crossing andthen stopped the bleeding. Patient then came to RSUKI to further therapy Head impact (+), chest impact (-), abdominal impact (-), vomiting (-), unconsciousness (-

), active bleeding (+).


17/49

17

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




SECONDARY SURVEY


18/49

18

Abdomen:

Ins : flat, bruise (-)

Aus : bowel sound (+) 6 x/min

Pal : Supel, tenderness (-), musculardefense (-)

Per : tympani

Extremity: Warm extremities, cap. refill time < 2,

edema (-)


19/49

19

Localized Status

Regio Parietalis

L : bleeding (+), vulnus laceratum 3x

0,5x 0,5 cm

F : crepitation (-)


20/49


21/49

21

Diagnosis

Vulnus laceratum regio parietalis


22/49

22

TREATMENT

Wound toilet

Hecting

MM : ketesse


23/49

Emergency Room

Morning Shift ReportMarch ,31st 2013

1 non-trauma patient


24/49

Mr. M ( 36 YO)

Chief complain :

- right pelvic pain

Additional complain :

- vomitting


25/49

History of illness :

Patient came to IGD RSU UKI with complaints ofright pelvic pain since two hours before coming to the

hospital. The pain was radiating to the right lower

abdomen. This complaint is felt when the patientbegins to micturition. Patients could micturition but a

few minutes later when the patient wants to

micturition, the patient should straining and finally justlet out a little micturition. History of pain during

micturition (-), history of weak micturition (-)


26/49

General ExaminationGC : Look moderate illness

E4M6V5 compos mentis

BP: 150/90mmHg

HR : 80 x/m

RR: 24 x/m

T : 36,3C


27/49

Localized examination :

Head: normocephali Eyes: CA -/-, SI -/-, pupil isochor 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect

Light Reflex +/+ Ear : normal

Neck : Lymph node enlargement (-)


28/49

Thorax :

Insp : bruise (-), movement of chest wall

symmetrical

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

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

Aus : Basic breath sound vesiculer


29/49

Abdomen :

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

Aus: bowel sound (+) 3x/minPal : right lower abdominal tenderness (+)

Per: timpani, percussion pain (-), percussion

pain CVA +/- , ballotement -/-


30/49

Suprapubic Region :

circumcision (+)

phimosis (-)

mass (-)

Rectal Touche :

Insp: fistula ani (-), fisura ani (-),mass (-), hiperemis (-), faeces(-),

blood(-)


31/49

Rectal touche :

Pal: TSA (+), ampulla recti not collapse,

prostate size laterolateral 2cm-2cm,

nodule(-), upper pole palpable, mass (-),

tenderness (-)

Extremity :

warm extremities, cap. refill < 2, edema (-)


32/49


33/49

Diagnose

Cholic ureter ec susp. ureterolithiasis

dd: nefrolithiasis


34/49

Treatment

Pro Hospitalized

Diet : normal

IVFD : I RL

MM : - ceftriaxone 2x1 gr (skin test)

- ranitidin 2x1 amp

- buscopan drip


35/49

1. An D(8 YO)

M : scalded by hot water

I : Regio aksila and scapula dextra

S : pain on the wound

T : immediately washed down with

cold water and given ointment

bioplacenton, then taken to the clinic

and was given antibiotics, analgesics

and ointments bioplacenton.


36/49

Airway : Clear (No gargling, No Stridor,

No Snooring)

Conclusion : clear

Breathing : Insp: bruise -, chest wall movement

symmetrical, RR 24 x/min

Pal : crepitation -



Conclusion : No pneumothorax, no

hematothorax


37/49

C = warm extremities, Pulse = 96bpm ,

BP 120/80mmHg, Temp= 36,50C,

capillary refill


38/49

Secondary Survey

Chief complaint : pain on the wound

Additional complaint : no additional

complaint


39/49

History of illness (auto anamnesis) :

1 hour before admissions, patient got a singleaccident while she scalded by hot water. the affected

body part is the right chest and back right. At that time

the patient's grandmother had just taken the hot water

from the dispenser and the patient suddenly hit her

grandmother was so affected by the hot flush. Sometime

after exposure to hot water is instantly the patient's skin

was flushed to blister and peel. Patients immediately

washed down with cold water and topical ointments

bioplacenton then brought to the clinic and givenantibiotics, analgesics and bioplacenton.

No visible signs of shock


40/49

AMPLE

Allergy : -

Medication : Bioplacenton

Past Illness : -

Last Meal : -

Event : scalded by hot water


41/49

HEAD TO TOE

Head: Bruise (-),oedem (-), Hematom (-),

blood ( -), swelling (-)

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

centered, Direct Light Reflex +/+, Indirect

Light Reflex +/+,Ear : Bruise (-), hematom (-)

Neck : Bruise (-), hematom (-)


42/49

Thorax :

Insp : bruise (-), movement of

chest wall

symmetrical,

Pal : crepitation (-), pain on

palpation (-)

Per : sonor right = left,

percussion pain (-)



43/49

Abdomen :

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

defense (-),

Aus : bowel sound (+) 4x/minPal : tenderness (-)

Per : Percusion tenderness (-)

Extremity :

warm extremities, cap. refill < 2, edema (-)


44/49

Localized status

Regio aksila dextra

L: burns skin with epidermal tissue

disappears, eritema +,bulla+

F: palpation pain +Regio scapula dextra

L: burns skin with epidermal tissue

disappears, eritema +, bulla +F: palpation pain +


45/49

Regio Photo


46/49

Primary Survey

Airway : Clear (No gargling, No Stridor,No Snooring)

Conclusion : clear

Breathing : Insp: bruise -, chest wall movement

symmetrical, RR 24 x/min

Pal : crepitation -



Conclusion : No pneumothorax, no

hematothorax


47/49

C = warm extremities, Pulse = 96bpm , BP120/80mmHg, Temp= 36,50C, capillary refill


48/49

Diagnosa

Scalding burn grade IIA 10%,

regio aksila dextra and scapula

dextra.


49/49

TREATMENT

IV line (Rl )

Wound toilet

Mm / ( analgetic, antibiotic, ATS)

Observation on vital sign and wound

care treatment.

Documents

Morpot Alex