Night Shift Report

November 2nd 2014

Asisstant:
dr.Rico, dr.Benny
Co.asisstant:
Ni Galuh Wibhutisari
Cristina Ronauly
Medianto Sinabutar
Erika agustiani
Gabriel Hutabarat
Dumasari Septiani
Dwi Arum
Elysabeth MS

Trauma: 2

Hospitalize: 1

Non-Trauma: 2

Non-Hospitalize: 3

1. Mr. B (20 Years Old)

80.06.06.00
Mechanism of the Trauma
motorcycle accident
Injury of target organ
Digiti IV Manus sinistra
Symptoms and signs
Open Fracture
Treatment Pre Hospital (Before UKIS ER)
Patient came to RS. Harapan Bunda

PRIMARY SURVEY
Airway : CLEAR
Look : no obstruction
Listen : no extra breath sound (no gurgling, no snoring,
no stridor, no horseness)
Feel : there were warm air from both nose and mouth

Breathing : CLEAR
Inspection: RR 20 x/min,bruise (-), chest wall
movement,trachealdeviation(-),Retraction of
intercostae(-),symmetrical.
Pal
: crepitation (-)
Per
: sonor right = left
Aus : Basic breath sound bronchial, rh -/-, wh -/-

 Circulation : No Sign Of Shock

Warm extremities, CRT <2
Pulse = 100 x/menit
Temp = 36,50C
TD=130/80mmhg

Disability
GCS 15 (E4M6V5) pupil isochoric 3/3 mm,
centered,
Direct light reflex/indirect light reflex +/
+

Exposure
Open fracture digiti IV manus sinistra +
exchoriasi at PIP digiti IV manus sinistra.

Secondary Survey
AMPLE
Allergy
: Medication
: Past Illness
: Last Meal : in the morning
Event
: accident

HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric
3mm/3mm,
centered, Direct
Light Reflex +/+,
Indirect
Light Reflex +/+, CA -/Ear : normal, LCS (-), blood (-)
Neck : Bruise (-), hematoma (-)

Thorax :
- Inspection

: movement of chest wall

symmetrical
- Palpation : Vocal Fremitus symmetrical,
crepitation (-)
- Percussion : sonor right = left
- Auscultation:
Basic
breath
sound
Vesicular
right=left, wh-/-, rh-/-.

Abdomen
- Inspection : flat
- Auscultation : bowel sound (+)
4x/min
- Palpation
: tenderness (-),
defense
muscular (-)
- Percussion : tympani, percussion
pain (-)

Look: open fracture at

digiti IV manus sinistra,
edema (+), blood (+),
active bleeding (-), pus
(-). Exchoriasi (+) at
digiti IV and digiti III
manus sinistra, Base of
wound: Bone.
Feel: pain on palpation
(+)
Move: active with
limitation

 Extremities
Warm acral, capillary refill time <2
seconds

RADIOLOGI

Jenis
Pemeriksaan

Hasil

Satuan

Nilai Rujukan

Natrium

144 L

Mmol/L

136-145

Kalium

3.9

Mmol/L

3,5-5,1

Klorida

107

Mmol/L

99-111

Hemoglobin

15.3 L

g/dl

12-14

Leukosit

7.9

Ribu/ul

5-10

Hematokrit

45.3

37-43

Trombosit
Ureum darah

190
17

Ribu/ul
Mg/dl

150-400
15-45

Creatinin
darah

1,06

Mg/dl

0,60-0,90

Gula darah
sewaktu

84

Mg/dl

<200

M. Perdarahan

1.30

Menit

1-3

M.Pembekuan

12

Menit

10-16

M.Protrombin

13

Detik

10-16

History of illness
Patient came to the ER 1 day after
got a motorcycle accident (spion
crash). History of falling from
motorcycle (-). Before came to ER
patient already got treatment in RS.
Harapan Bunda.

Working diagnose
- Traumatic amputasi phalanx distal digiti
IV manus sinistra
- Closed fracture metacarpale digiti IV
manus sinistra

TREATMENT
Non Medicamentosa :
- Hospitalized
- Pro V-Y Plasty + ORIF
Medicamentosa :
IVFD: 1 RL + Tofedex 3 amp / 24 jam
- Terfacef 3x1 gr (IV)
- Ranitidin 2x1 amp (IV)

2. Ms. M (21Years Old)

14.06.06.00
Mechanism of the Trauma
Motorcycle crash injury
Injury of target organ
Lower leg dextra
Symptoms and signs
Pain, Swelling, hematoma
Treatment Pre Hospital (Before UKIS ER)
-massage (2 times)

History of illness
Patient female 21 years old came to the ER with
complaints of pain on knee 3 days before came to ER,
when patient wants to cross the road suddenly a
motocycle from right side crash over her and she fall to
the ground after the accident she go to tukang urut on
Thrusday and Saturday. Then patient go to UKI hospital
on Monday to check her knee condition.

PRIMARY SURVEY
Airway
: CLEAR
Look : no obstruction
Listen : no extra breath sound
Feel : there were warm air from both nose and mouth
Breathing : CLEAR
Ins : chest wall movement symmetrical, RR 18x/min,
bruise (-), hematoma ()
Pal
: vocal fremitus symmetrical
Per
: sonor right = left
Aus : basic breath sound vesicular, rh -/-, wh -/-

 Circulation : No Sign Of Shock

Warm extremities
Pulse = 82 x/menit
Temp = 360C
CRT <2
Disability
GCS 15 (E4M6V5)
pupil isochoric 3/3 mm, centered
Direct light reflex/indirect light reflex +/+
Exposure
There was no life threatening wounds

SECONDARY SURVEY
AMPLE
Allergy
: Medication
: Past Illness
: Last Meal : In the morning
Event
: Accident

HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm, centered,
Direct Light Reflex +/+, Indirect Light Reflex +/+,
CA -/Ear : Normal, LCS (-), Blood (-)
Neck : Bruise (-), Hematoma (-)

Thorax :
- Inspection : bruise (-), movement of chest wall
symmetrical
- Palpation: Vocal fremitus symmetrical
- Percussion : sonor right=left, percussion pain (-)
- Auscultation: basic breath sound vesicular
right=left, wh-/-, rh-/-.

Abdomen :
- Inspection
: flat
- Auscultation: bowel sound (+) 4x/min
- Palpation : tenderness (-), defense muscular
(-), pain palpitation (-)
- Percussion : tympani, percussion pain (-)

Status Localis : Genu &

cruris dextra
Look
Edema (+)
Blood (-) Active bleeding
(-) Hematoma (+)

Feel
Pain in palpation (+)

Movement
Active with limitation ion
movement

Radiologic: Genu dextra

Working diagnose
Kontusio jaringan genu dextra

TREATMENT
Non-Medicamentosa:
Non-Hospitalize
Medicamentosa :
- Lanfix 2x200 mg
- Ranitidin 2x1 tab
- Tofedex 3x1 tab