Emergency Unit

Night Shift Report

July, 31st 2011
1. Mr. S ( 52 YO)
PRIMARY SURVEY
• Self protection (gloves)
• Patient can talk coherently in a long
sentence
• Patient was brought by her family
 PHYSICAL EXAMINATION

• Airway : Clear
• Breathing :
Insp : movement of chest wall symmetrical, bruise (-),
RR : 18 x/mins
 Pal : VF right = left, crepitation (-), pain on palpation
(-)
 Per : sonor right = left, pain on percussion(-)
 Aus : Basic breath sound vesicular, wh -/-, rh-/-
 PHYSICAL EXAMINATION

• C = Warm extremities, Pulse = 74 x/min ,

BP =120/80 mmHg, temperature = 36,5 °C, capillary
refill time< 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 SURVEY

• Chief complain : chest pain on the right

side
• Additional complain : pain in the wrist when
moving
 SECONDARY SURVEY
• History of Illness :
Approximately 1 day before admission the patient suffered
a motorcycle accident. Patients rub against the car from
the front and fell to the right. Patient's chest hit the
motorcycle handlebar. Patients wearing full-face helmet
and bike speed of 40 km per hour. after the incident
patients are sorted by the masseur. this time the patient
complained of chest pain in the lower right, especially
when coughing. Diabetes melitus history positive and do
not regularly take medication
• Head impact (-), Chest impact (+), Abdominal impact (-),
shortness of breath (-), unconsciousness (-), amnesia (-),
headache (-), vomit (-), nausea (-).
AMPLE

• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : 4 hours before admitted
hospital
• Event : motorcycle accident
HEAD TO TOE
General Examination
• Head : Bruise (-) , edema (-) tumor (-), blood (-), wound (-)
• Eyes : Pupil round, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA-/-, SI-/-
• Neck : Bruise (-), hematoma (-), nn.ll no palpable
enlargement
• Thorax
Insp : movement of chest wall symmetrical, bruise (+) in the
left upper thoracic
Pal : VF right = left, crepitation (-), pain on palpation (+)
in the right lower thoracic
Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound vesicular, wh -/-, rh-/-
Abdomen
Insp : flat, hematoma (-), bruise (-),
muscular defense (-)
Palp : smooth, H/L no palpable enlargement
Perc : Tympani, pain on percussion (-)
Ausc : bowel sound (+) 4x/min

Extremities
cap. Refill time< 2”, warm extremity, edema (-),
bruise (-), hematoma (-)
Finger in every orifices
• Nose : Blood (-), LCS (-)
• Ear : Blood (-), LCS (-)
• Mouth : Blood (-)
• Anus : Blood (-)
• OUE : Blood (-)
Additional Examination
Roentgen thorax AP
Laboratorium
• GDS : 373 mg/dl
DIAGNOSIS
Blunt thoracic trauma
TREATMENT

- Mm : Cefixime 2 x 1 mg
Ketesse 3 x 1 mg
Ranitidine 2 x 1 mg
- Patient go home
 2. Mr. Z ( 47 YO)
• Chief complain : pain in lower leg
• Additional complain :-
History of illness
• Patient is a referral from rs budi asih
compassion to the surgery by the internal.
Come with complaints of pain from the
knees down. after being treated in hospital
for 20 days does not heal. patients had a
history of diabetes mellitus since 1997.
blood sugar controlled with oral
medication. patients also had a history of
high cholesterol. patients also complained
of pain in addition to her feet numb.
positive swollen and there is a bubble
filled with water that has been broken
General Examination
• Head : Bruise (-) , edema (-) tumor (-), blood
(-), wound (-)
• Eyes : Pupil round, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+,
Indirect Light Reflex +/+, CA-/-, SI-/-
• Neck : Bruise (-), hematoma (-), nn.ll no
palpable enlargement
• Thorax
Insp : movement of chest wall symmetrical, bruise (-)
Pal : VF right = left, crepitation (-), pain on palpation
(-)
Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound vesicular, wh -/-, rh-/-
• Abdomen
Insp: flat, hematoma (-), bruise (-),
muscular defense (-)
Palp : smooth, H/L no palpable enlargement
Perc : Tympani, pain on percussion (-)
Ausc: bowel sound (+) 4x/min

• Extremities
cap. Refill time< 2”, warm extremity, edema (+)
bruise (-), hematoma (-)
Status Lokalis Regio Cruris et
Pedis Sinistra
• Look : ekskoriasi, necrotic tissue
• Feel : cold, oedem, painless, pultation
(-)
• Move : aktive movement limited,
passive movement unlimitted
 Laboratorium
• Hb: 10 g/dl • Blood creatinin : 0,78
• Ht: 18,8 % mg/dl
• Leucocyte: 28,9 /ul • GDS :219 mg/dl
• Trombocyte:470/ul • Na : 136 mmol/L
• Bleeding time : 1,3 • K : 4 mmol/L
• Cloting time : 12,3 • Cl : 108 mmol/L
• PT Time : 12 mg/dl
• PT Control : 13 mg/dl
• Blood ureum : 39
mg/dl
Diagnosis
• Kronik Limb Ischemic
Treatment
1. Pro hospitalized
2. Pro amputatio pedis sinistra above
the knee
3. IVFD : NS 0,9 % /24 hour
4. Mm : - Metronidazole 3 x 500 mg
- Meronem inj 3x 1