Emergency Room

Morning Shift Report

January, 14th 2014

1. Mr. D (25 YO )
M I S

: Fall from motorcycle : Regio Frontal dextra : Wound dan active bleeding :-

Primary Survey
Airway

: Clear ( snoring -, gurgling -, stridor - )

Breathing : Insp : bruise (-), chest wall movement symmetrical, RR 22 x/ min, hematoma (-), wound (-) Pal : crepitation sub cutis (-) Per : sonor right = left Aus : Basic breath sound vesicular similar right and left

Primary Survey
C

= warm extremities, Pulse = 82bpm, BP 120/100mmHg, Temp = 36,3C, capillary refill time < 2sc = GCS E4M6V5, pupil isochors 3mm/3mm, centered, direct light reflex/ indirect light reflex +/+ = there is no life threatening wound

History of illness
Patient came to the hospital with complain in the right

side of the head continuous pain perceived. Initially patiens experienced motorcycle accident. The motorcycle swerved to a void a car dan then crush into the right side. Patient falls with the right arms first and then the head. Patient also complaint there are abrasions on both legs. Nausea and vomit (-), Fainting (-), headache (-), Active bleeding (+).

HEAD TO TOE Head : wound 4x1x0.3 Eyes : pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+ Ear : Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-) Thorax : Insp : bruise (-), wound (-), movement of chest wall symmetrical Pal : crepitation (-), tenderness (-) Per : sonor right = left Aus : Basic breath sound vesicular similar right and left

 Abdomen :

Ins Aus Pal Per

Extremity:

: flat, bruise (-) : bowel sound (+) 6x/min : Supel, tenderness (-), muscular defense (-) : tympani

Warm extremities, cap. refill time < 2

Localized status
Regio frontalis dextra L : wound (+) 4x1x0.3 bleeding (+) puffiness (-) F : tenderness (+), crepitation (-), pallor (-), poikilotermi (-), parestesis (-) M:-

Foto thorax

Foto schedel

CT Scan

Diagnosis
CKR+ Vulnus laseratum regio frontalis dextra

Multiple vulnus eskoriasi

Treatment
Non medica mentosa

Rawat inap
Wound Toilet, Hecting Medicamentosa ATS

2. Mr H (55 Y.O)
PRIMARY SURVEY M : Motorcycle accident I : Pain on his left chest S : Pain on injury T : (-)

Primary Survey
Airway : Clear (snoring -, gurgling -, stridor ) Breathing Insp :chest wall movement symmetrical, RR 20x/min, bruise (-). Pal : crepitation Per : sonor symmetrical Aus :Basic breath sound vesiculer, rhonki /-, wheezing -/Clear

Circulation Warm acral, pulse: 84 x/min, blood pressure: 120/90 mmHg, CRT <2 Clear Disability GCS E4M6V5 pupil isochoric 3/3 mm, centered, direct light reflex/indirect light reflex +/+ , lateralization (-) Clear E = Theres no life threatening wound

AMPLE
Allergy Medication Past Illness go)

::: DM (since 7 month a

Hypertension (since 1

year a go)

Last Meal admittance Event

: 2 hours before : Motorcycle accident

 Chief complain

Pain on his left chest Additional complaint : History of illness (auto anamnesis) Patient came to the hospital with a complaint pain on his left chest. The pain was felt after the patient got accident

motorcycle. The accident started when he breake his

motorcycle and then after that his chest strike the handlebar of motorcycle . After that, he feels pain on his left chest,especially when he breath. Nausea (+), vomiting (+), headache (-). Unconsciousness denied, chest impact (+), abdomen impact (). Patient still remember the accident.

HEAD TO TOE General Examination Head : Bruise (-), Normocepali. Eyes : Conjungtiva anemis -/-, sclera icteric -/-, Pupil circular, isochoric 3mm/3mm, centered Direct Light Reflex +/+, Indirect Light Reflex +/+. Neck : bruise (-). Thorax Insp : movement of chest wall symmetrical. Bruise (-) Pal : vocal fremitus right = left, tenderness (+), krepitasi (+) Per : sonor right = left Aus : Basic breath sound vesiculer, Rh -/-, Wh -/-

heart sound regular, murmur (-), gallop (-)

Abdomen Ins : flat, bruise (-), distended (-) Aus : bowel sound (+) 8x/min Pal : Supel, tenderness (-) Per : tympani, percussion pain (-) Extremity warm acral, cap. refill < 2,edema (-)

Localized status
Regio thorakalis L : movement of chest wall symmetrical right =left F : pulse (-), tenderness (+), crepitation (+), pallor (-), poikilotermi (-), parestesis (-) M:-

Foro rontgen thorakalis

Diagnosis
Trauma tumpul thorak + NIDDM

Treatment
Non medicamentosa Pro hospitalized Diet : DM
medicamentosa IVFD : I RL + III amp ketorolac /24 jam MM: Ceftriaxone 2x1 g (Skin test) Ranitidine 2x1