morpot13
TRANSCRIPT
M AY, 1 3 T H 2 0 1 1
Emergency Room
Night Shift Report
1 patient trauma
1. child A (1 1/2 YO)PRIMARY SURVEY
Self protection (gloves) Collar neck Patient was brought by policeman friend because motorcyle accident Airway : ClearBreathing :
Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on posteriolateral sinistra proximately at costae 6
Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae 5
Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/- , rh-/+
C = warm extremities, Pulse = 80 x/min , BP = 120/80 mmHg,Temp = 36,5°c, capillary refill < 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 Survey1. Mr. IN (15 YO)
Chief complaint : pain at left foreheadAdditional complaint : pain at left chest when the patient
was breathing
SECONDARY SURVEY
History of illness : ±30 minutes before admittated to the hospital, the patient was
riding the motorcycle with estimated speed 40 km/h and then she was hit the busway separator. Suddenly she was fall from the motorcycle and patient full-faced helm was off from her head. Her left side (head and chest) was hit the asphalt. After fall from the motorcycle patient was unconscious 1 minute, after that patient woke up and then she unconscious again in less 1 minute. Patient complaining about the pain in her left temples and left chest, amnesia retrogade (+), nausea (-), vomiting (-), headache (-). Patient was taken to the hospital by police man after she woke up again.
AMPLE
Allergy : -Medication : -Past Illness : -Last Meal : 3 h before an accidentEvent : motorcycle Accident
HEAD TO TOE
General ExaminationGC : Look mild illness
E4V5M6 compos mentisBP : 120/80mmHgHR : 80x/mRR : 20x/mT : 36,5°CHead : Bruise -, Hematom -, tumor -, blood -Nose : normal, blood -, LCS -Eyes : Pupil round, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect Light Reflex +/+
Ear : normal, LCS -, blood -Neck : Bruise (-), hematom (-), nn.ll no
palpable enlarge
Thorax Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on
posteriolateral sinistra proximately at costae 6 Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae
5 Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/, rh-/+
AbdomenIns : flat, hematom (-), bruise (-), defence
muscular (-)Pal : tenderness (-) Per : Percusion tenderness (-), TympaniAus : bowel sound + 4x/m
Ekstremitascap. refill < 2”, edema (-), warm extremity,excoriasi regio
right elbow, dorsum pedis dextra.
Localized status
Regio frontotemporal L : vulnus
laceratum size o,5x0,5 cm bruise (-), oedem (+), hematome (+), active bleeding (-), passive bleeding (+),
F :tenderness (+), crepitation (-)
M : crepitation -
Infra orbita L : excoriasi 2x2
cm bruise (-), oedem (-), hematome (-), active bleeding (-), passive bleeding (-),
F :tenderness (+), crepitation (-)
M : crepitation -
DIAGNOSA
moderate head injury + oedem cerebri + contusio thorax
Foto x-ray
CT-scan
CT-scan
TREATMENT
HospitalizedO2 nasal kanul 3 lpm IVFD : - MM/ : antibiotic
antiemeticanalgetichaemostatic
3. Mr. S (60 YO)
Chief complaint : bleeding from the nose and mouth
Additional complaint : pain in the right shoulder
PRIMARY SURVEY
Self protection (gloves) Collar neck Patient was brought by policeman because motorcyle accident
Airway : ClearBreathing :
Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) Pal : crepitation (-), pain on palpation (-) Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/- , rh-/-
C = warm extremities, pulse = 78 x/min , BP = 140/100 mmHg, temp = 36,5°c, capillary refill < 2”
D = GCS 15 – E4V5M6, pupil isochoric dificult to asses, direct light reflex/indirect light reflex +/+, lateralization (-)
E = There’s no life threatening wound
Secondary survey
History;one half hour before entering the hospital the
patient was driving a motor with a speed of 40 km / h, and then plunged the hole and was thrown approximately one meter. Patients using the half-faced helmet, but the helmet came off and his face hit the asphalt. vomiting + (contains 10 cc of blood), nausea -, fainting -, collision chest +, + the head clash, collision abdominal -.
AMPLE
Allergy : -Medication : -Past illness : -Last meal : 9 h before accidentEven : traffic accident
Head to toe
General ExaminationGC : Look moderate illness
E4V5M6 compos mentisBP : 140/100mmHgHR : 78x/mRR : 20x/mT : 36,5°CHead : Bruise +, Hematom +, tumor -, blood +Nose : normal, blood -, LCS -Eyes : Pupil round, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect Light Reflex +/+
Ear : normal, LCS -, blood -Neck : Bruise (-), hematom (-), nn.ll no palpable
enlarge
Thorax Insp : RR: 20x/m, movement of chest wall symmetrical, bruise (+) on
posteriolateral sinistra proximately at costae 6 Pal : crepitation (-), pain on palpation (+) at line axilary anterior, costae 5 Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer, wh -/, rh-/+
AbdomenIns : flat, hematom (-), bruise (-), defence
muscular (-)Pal : tenderness (-) Per : Percusion tenderness (-), TympaniAus : bowel sound + 4x/m
Ekstremitascap. refill < 2”, edema (-), warm extremity,excoriasi regio
right elbow, dorsum pedis dextra.
Localized status
Regio Orbitalis Dextra L : oedem (+), hematome (+), active bleeding (-),
passive bleeding (+), F : tenderness (+), crepitation (-) M :
Regio zygoma Dextra L : excoriasi 2x2 cm bruise (-), oedem (-), hematome
(-), active bleeding (-), passive bleeding (-), F : tenderness (+), crepitation (-) M : crepitation -
Regio frontalis dextra L : excoriasi 6x2 cm the base is soft tissue, oedem
(-), hematome (-), active bleeding (-), passive bleeding (+),
F : tenderness (-), crepitation (-) M : crepitation –
Regio nasalis L : bleeding from the nose, active bleeding (+),
passive bleeding (-) F : tenderness (-), crepitation (-) M : crepitation –
Regio oris L : blood +, active bleeding (+), passive bleeding
(-) F : tenderness (-), crepitation (-)
diagnosa
mild head injury
Thorax Foto