morpot 141114

8/17/2019 MORPOT 141114

1/55

Night Shift Report November 14th November 2014

Asisstant:

dr.Kezia,dr.Benny

Co.asisstant:

Medianto Sinabutar Ni a!uh "ibhutisari

Cristina #onau!y

$ri%a a&ustiani

abrie! 'utabarat

(umasari Se)tiani

#i%i

8/17/2019 MORPOT 141114

2/55

*rauma: 4

Non+*rauma: +

'os)ita!ize: 1

Non+'os)ita!ize: 2

8/17/2019 MORPOT 141114

3/55

1. Mr. TG (40 Years Old)00.09.06.00

Mechanism of the Trauma

Motory!e+bus trans-a%arta aident

Injury of target organ

*hora%a!, abdomen

Symptoms and signs

Shourtness o breath

Treatment Pre Hospital (Before UI!S "R#+

8/17/2019 MORPOT 141114

4/55

PRIM$R% SUR&"%

• Air/ay : '"$R

– oo% : no obstrution

– isten : no etra breath sound no &ur&!in&, no snorin&,

no stridor, no horseness3 – ee! : there /ere /arm air rom both nose and mouth

• Breathin& : N)T '"$R

– 5ns)etion: ## 62 7min,bruise 83, hest /a!!

movement,trahea!deviation+3,#etration ointerostae+3,symmetria!.

– 9a! : re)itation +3, emisema sub%utan

– 9er : du!!7sonor

– Aus : Basi breath sound bronhia!, rh 878, /h +7+

8/17/2019 MORPOT 141114

5/55

• Circulation : Shock – Warm extremities, CRT

8/17/2019 MORPOT 141114

6/55

Seondary Survey

AMPLE

• ller#% :

• *e-ication :

• Past llness :

• ast *eal : in t"e a4ternoon

• )5ent : acci-ent

8/17/2019 MORPOT 141114

7/55

HEAD TO TOE

ea- : 7ormocep"al%)%es : Pupil circular, isoc"oric

3mm/3mm, centere-, !irect

i#"t Re.ex /, n-irecti#"t Re.ex /, C /)ar : normal, C' (, $loo- (7ec8 : 9ruise (, "ematoma (

8/17/2019 MORPOT 141114

8/55

T"orax : nspection : "ematom(

lpation : +ocal remitus s%mmetrical,

crepitation (, em;sema su$ 8utis( Percussion : pe8a8/"ipersonor

uscultation: 9asic $reat" soun-+esicular

ri#"t=le4t, "/, r"/

8/17/2019 MORPOT 141114

9/55

Abdomen

nspection : .at

uscultation : $oel soun- (

3x/min Palpation : ten-erness (,

-e4ense muscular (

Percussion : t%mpani, percussionpain (

8/17/2019 MORPOT 141114

10/55

8/17/2019 MORPOT 141114

11/55

• $tremities

Warm acral, capillar% re;ll time

8/17/2019 MORPOT 141114

12/55

#A(55

8/17/2019 MORPOT 141114

13/55

'istory o i!!ness

• 9atient ame to the $# at 1;.1< "5B

/ith hie om)!ain )ain on !et side

o the %nee ater &ot a motory!e+

bus trans-a%arta aident rash behind him. 9atient as a driver /ith

ha!+ae+he!met a!! to the !et side

o the road and his %nee &ot rash hismotory!e and bum)er bus

trans-a%arta. oss o oniousness +3

vomittin& +3 headahe +3

8/17/2019 MORPOT 141114

14/55

*or+ing diagnose

*rauma tum)u! tora%s, trauma tum)u!

abdomen, trauma !arin&

8/17/2019 MORPOT 141114

15/55

*#$A*M$N*

Air/ay

$** 8Breathin& hest tube 8 , darah 29 6 Si%!us tida% res)ons

8/17/2019 MORPOT 141114

16/55

2. Mr. Eylon (33 YearsOld)

99.09.06.00Mechanism of the TraumaMotory!e+bus trans-a%arta aident


et %nee

Symptoms and signs

9ain on %nee

Treatment Pre Hospital (Before UI!S "R#+

8/17/2019 MORPOT 141114

17/55

PRIM$R% SUR&"%

• Air/ay : '"$R


– isten : no etra breath sound no &ur&!in&, no snorin&,

no stridor, no horseness3 – ee! : there /ere /arm air rom both nose and mouth

• Breathin& : '"$R

– 5ns)etion: ## 20 7min,bruise +3, hest /a!!

movement,trahea!deviation+3,#etration ointerostae+3,symmetria!.

– 9a! : re)itation +3

– 9er : sonor ri&ht ? !et

– Aus : Basi breath sound bronhia!, rh +7+, /h +7+

8/17/2019 MORPOT 141114

18/55

• Circulation : No Sign Of Shock – Warm extremities, CRT 0C

– T!=120/0mm"#

•

!isa$ilit% – &C' 1 ()?*6+ pupil isoc"oric 3/3 mm,

centere-,

– !irect li#"t re.ex/in-irect li#"t re.ex /

• )xposure :

8/17/2019 MORPOT 141114

19/55

Seondary Survey

AMPLE

• ller#% :

• *e-ication :

• Past llness :

• ast *eal : in t"e a4ternoon

• )5ent : acci-ent

8/17/2019 MORPOT 141114

20/55

HEAD TO TOE

ea- : 7ormocep"al%)%es : Pupil circular, isoc"oric

3mm/3mm, centere-, !irect

i#"t Re.ex /, n-irecti#"t Re.ex /, C /)ar : normal, C' (, $loo- (7ec8 : 9ruise (, "ematoma (

8/17/2019 MORPOT 141114

21/55

T"orax : nspection : mo5ement o4 c"est all

s%mmetrical

Palpation : +ocal remitus s%mmetrical,crepitation (

Percussion : sonor ri#"t = le4t

uscultation: 9asic $reat" soun-

+esicularri#"t=le4t, "/, r"/@

8/17/2019 MORPOT 141114

22/55

Abdomen

nspection : .at

uscultation : $oel soun- (

6x/min Palpation : ten-erness (,

-e4ense muscular (

Percussion : t%mpani, percussionpain (

8/17/2019 MORPOT 141114

23/55

#e&io: 176 )roima! ruris

sinistra

Look : +ulnus exsc"oriasi (, e-ema (,$loo- (, acti5e $lee-in# ( #enusinistra, 9ase o4 oun-: su$8utis@

Feel: pain ( crepitation (

Move: acti5e it" limitation

8/17/2019 MORPOT 141114

24/55

• $tremities Warm acral, capillar% re;ll time

8/17/2019 MORPOT 141114

25/55

#A(55

8/17/2019 MORPOT 141114

26/55

8/17/2019 MORPOT 141114

27/55

'istory o i!!ness




bus trans-a%arta aident rash bihindhim. 9atient as a driver /ith ha!+

ae+he!met a!! to the !et side o the

road and his %nee &ot rash hismotory!e and bum)er bus

trans-a%arta. oss o oniousness +3

vomittin& +3 headahe +3

8/17/2019 MORPOT 141114

28/55

*or+ing diagnose

- Contusio Musu!osum re&io &enu sinistra

8/17/2019 MORPOT 141114

29/55

*#$A*M$N*

Non Mediamentosa :- 'os)ita!ize

+ bservation

Mediamentosa :• $!asti verban no.@ inh

• 9iroiam &e!

• 5(: 1# 8 i%aneuron 7 24-am

• mm7 er&oti%a tab 21

8/17/2019 MORPOT 141114

30/55

,- Mr- Patric+ (,. %ears )ld#

/,-0/-/1-//


5ndividua! motory!e aident


Manus detra+sinistra, &enu detra, tarsa! sinistraSymptoms and signs

9ain mu!ti)!e vu!nus ehoriasi

Treatment Pre Hospital (Before UI!S "R#

+

8/17/2019 MORPOT 141114

31/55

History of illness

9atient ma!e 26 years o!d ame to the $# at 21.

8/17/2019 MORPOT 141114

32/55

PRIM$R% SUR&"%

• Air/ay : '"$R


– isten : no etra breath sound

– ee! : there /ere /arm air rom both nose and mouth


– 5ns : hest /a!! movement symmetria!, ## 217min,

bruise +3, hematoma 3

–

9a! : voa! remitus symmetria! – 9er : sonor ri&ht ? !et

– Aus : basi breath sound vesiu!ar, rh +7+, /h +7+

8/17/2019 MORPOT 141114

33/55

• Ciru!ation : No Sign )f Shoc+

– "arm etremities

– 9u!se ? DE 7menit

– *em) ? 6D,

8/17/2019 MORPOT 141114

34/55

S"')N2$R% SUR&"%

$MP"

• A!!er&y : +

•Mediation : +

• 9ast 5!!ness : +

• ast Mea! : 5n the aternoon

•

$vent : Aident

8/17/2019 MORPOT 141114

35/55

H"$2 T) T)"

Head : Normoe)ha!y

"yes : 9u)i! iru!ar, isohori 6mm76mm, entered,

(iret i&ht #e!e 878, 5ndiret i&ht #e!e 878,

CA +7+"ar : Norma!, CS +3, B!ood +3

Nec+ : Bruise +3, 'ematoma +3

8/17/2019 MORPOT 141114

36/55

Thora3 4 5ns)etion : bruise +3, movement o hest /a!!

symmetria!

9a!)ation: oa! remitus symmetria!

9erussion : sonor ri&ht?!et, )erussion )ain +3

Ausu!tation: basi breath sound vesiu!arri&ht?!et, /h+7+, rh+7+.

8/17/2019 MORPOT 141114

37/55

$5domen 4

5ns)etion : !at

Ausu!tation: bo/e! sound 83 @7min

9a!)ation : tenderness +3, deense musu!ar+3, )ain )a!)itation +3

9erussion : tym)ani, )erussion )ain +3

8/17/2019 MORPOT 141114

38/55

Status ocalis 4 manus de3tra

6 sinistra•

oo+ u!nus ehoriasi

83 $dema +3

B!ood 83 Ative b!eedin& +3

'ematoma +3

• 7eel

9ain 83

• Mo8ement

un!imited

8/17/2019 MORPOT 141114

39/55

Status ocalis 4 genu sinistra

•oo+ u!nus ehoriasi 83$dema +3

B!ood 83 Ative b!eedin&

+3 'ematoma +3

• 7eel

9ain 83

• Mo8ement

un!imited

8/17/2019 MORPOT 141114

40/55

Status ocalis 4 tarsal sinistra

•oo+ u!nus ehoriasi 83$dema +3


+3 'ematoma +3

• 7eel

9ain 83

• Mo8ement

un!imited

8/17/2019 MORPOT 141114

41/55

Status ocalis 4 hip sinistra

•oo+ u!nus ehoriasi +3$dema +3 B!ood +3 Ative

b!eedin& +3 'ematoma 83

• 7eel9ain 83

• Mo8ement

+

8/17/2019 MORPOT 141114

42/55

*or+ing diagnose

Mu!ti)!e vu!nus ehoriasi re&io manus

detra sinistra, &enu sinistra dan tarsa!is

sinistra 8 hematom hi) sinistra.

8/17/2019 MORPOT 141114

43/55

*#$A*M$N*

Non9Medicamentosa4 Non+'os)ita!ize

"ound toi!ette

Medicamentosa 4Ana!&eti% de%eto)roen3 tab 21

#anitidine tab 21

8/17/2019 MORPOT 141114

44/55

:- Mr- Suryanto (,; %ears )ld#

/0-0/-/1-//


Motory!e+bus trans-a%arta aident


Ca!aneus sinistraSymptoms and signs

vu!nus ehoriasi

Treatment Pre Hospital (Before UI!S "R#

+

8/17/2019 MORPOT 141114

45/55

History of illness

9atient ma!e 26 years o!d ame to the $# at 21.

8/17/2019 MORPOT 141114

46/55

'istory o i!!ness




bus trans-a%arta aident rash bihindhim. 9atient as a driver /ith ha!+

ae+he!met a!! to the ri&ht side o

the road. oss o oniousness +3vomittin& +3 headahe +3

8/17/2019 MORPOT 141114

47/55

PRIM$R% SUR&"%

• Air/ay : '"$R


– isten : no etra breath sound

– ee! : there /ere /arm air rom both nose and mouth


– 5ns : hest /a!! movement symmetria!, ## 207min,

bruise +3, hematoma 3

–

9a! : voa! remitus symmetria! – 9er : sonor ri&ht ? !et

– Aus : basi breath sound vesiu!ar, rh +7+, /h +7+

8/17/2019 MORPOT 141114

48/55

• Ciru!ation : No Sign )f Shoc+

– "arm etremities

– 9u!se ? D2 7menit

– *em) ? 6@,

8/17/2019 MORPOT 141114

49/55

S"')N2$R% SUR&"%

$MP"

• A!!er&y : +

•Mediation : +

• 9ast 5!!ness : +

• ast Mea! : 5n the aternoon

•

$vent : Aident

8/17/2019 MORPOT 141114

50/55

H"$2 T) T)"

Head : Normoe)ha!y

"yes : 9u)i! iru!ar, isohori 6mm76mm, entered,

(iret i&ht #e!e 878, 5ndiret i&ht #e!e 878,

CA +7+"ar : Norma!, CS +3, B!ood +3

Nec+ : Bruise +3, 'ematoma +3

8/17/2019 MORPOT 141114

51/55

Thora3 4 5ns)etion : bruise +3, movement o hest /a!!

symmetria!

9a!)ation: oa! remitus symmetria!

9erussion : sonor ri&ht?!et, )erussion )ain +3

Ausu!tation: basi breath sound vesiu!arri&ht?!et, /h+7+, rh+7+.

8/17/2019 MORPOT 141114

52/55

$5domen 4

5ns)etion : !at

Ausu!tation: bo/e! sound 83 @7min

9a!)ation : tenderness +3, deense musu!ar+3, )ain )a!)itation +3

9erussion : tym)ani, )erussion )ain +3

St t li l

8/17/2019 MORPOT 141114

53/55

Status ocalis 4 calcaneus

sinistra•

oo+ u!nus ehoriasi 83$dema +3


+3 'ematoma +3

• 7eel

9ain 83

• Mo8ement

un!imited

8/17/2019 MORPOT 141114

54/55

*or+ing diagnose

vu!nus ehoriasi on the !et side o

a!aneus

8/17/2019 MORPOT 141114

55/55

*#$A*M$N*

Non9Medicamentosa4 Non+'os)ita!ize

"ound toi!ette

Medicamentosa 4Ana!&eti% de%eto)roen3 tab 21

#anitidine tab 21

morpot 141114

Documents