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Emergency Unit

Night Shift ReportAugust, 23rd2014

Assistant:

dr. HendyCo-assistant:

Melissa Ronaldi ( Chief)

Novena

Etriansa Widiens Orno

Anastasia F

Michael

Cynthia Dasuki

Zega Agustian

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Trauma: 2

Non Trauma: 1

Hospitalize: 1

Non Hospitalize: 2

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1. Boy I

(13Years Old)

04.85.05.00

TAC : 16.00 (August, 22 2014)

TAR: 13.00 ( August 23, 2014)

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PRIMARY SURVEY

Airwaysnoring (+)Guedelclear

Breathing : CLEAR

Circulation :N: 120 bpm TD 130/70 mmHg

Disabillity GCS E2V2M5 pupil anisokor D >S

Exposure: threrewas no life threatening wounds

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AMPLE

Allergy : -

Medication : -

Past Illness : -

Last Meal : yesterday

Event : accident

Secondary Survey

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History of illness

Patient came to the ER with the complaints ofloss of consciousness since one day before

admission. Patient fall from motorcycle, and he

landed with his head hit the sidewalk. Patient

didnt wear helmet. Then, patient was brought to

RSUD Cibinong and He got IV line, CT Scan

and medicine but there was no neurosurgery in

RSUD Cibinong so Patient transfered to UKIsER. Patient had fever and seizures.

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HEAD TO TOE

Head : bruise (+)

Regio frontozygomatica

dextraLook : vulnus excoriation (18

x 5 cm), blood (+), active

bleeding (-), oedem (+)Feel : crepitation (-)

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Eyes : Pupil circular, anisochoric 7mm/3mm,

centered, Direct Light Reflex +/+, IndirectLight Reflex +/+, CA -

Regio infra orbita dextraLook : bruise (+), oedem (+), blood (-), active

bleeding (-)

Feel :crepitation (-)

Ear : normal, LCS (-), blood (-)

Neck : Bruise (-), hematoma (-)

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Thorax :- Inspection : bruise (-), movement of chest wall

symmetrical

- Palpation : not doing

- Percussion : sonor

- Auscultation: Basic breath sound Vesicular

right=left, wh-/-, rh-/-.

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Abdomen

- Inspection : flat, bruise (-),

- Auscultation : bowel sound (+) 6x/min

- Palpation : defense muscular (-)

- Percussion : tympani

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Extremities

warm acral, capillary refill time

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Working Diagnosis

Severe Head Injury susp Intracranial

Bleeding

Vulnus excoriation regio frontozygomatica

dextra

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CT Scan

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Chest X-Ray

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Diagnosis

Severe Head Injury

Impression Fracture frontal dextra

Vulnus Excoriation frontozygomatica

dextra

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TREATMENT

Non Medicamentosa :- Hospitalized

- Wound Toilet

- Pro Craniotomy

- Intubation

Medicamentosa :

IVFD : RL 20 drips/minute

mm/ Ceftraixone 2x 1 gr (IV)

Manitol 1x 100 ml (drip)

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16.30

Patient went under supervision and

GCS decrease E1V1M4intubation

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17.30

Patient went to operating theater to

perform craniotomyfound dura

laserationCraniotomy +

Duraplasty

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2. Mrs. L(51Years Old)

15.78.05.00

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PRIMARY SURVEY

Airway : CLEAR

Breathing : RR= 18 x/minuteCLEAR

Circulation : BP = 150/90, HR= 92x/minute

Disability : GCS 15 E4M6V5

Exposure : There was no life threatening wounds

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AMPLE

Allergy : -

Medication : -

Past Illness : -

Last Meal : in the afternoon

Event : accident

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History of illness

Patient came to UKIs ER with the

complaints of pain on her elbow, knee and

feet since 30 minutes before came to hospital.

Pain were sharpy and continously. Patientrode motorcycle and hit from behind by a car

and her right body hit the road. Patient wore

helmet. Head injury denied, loss of

consciousness denied, vomit denied. Thenpatient was brought to UKIsER without any

treatment.

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SECONDARY SURVEY

HEAD TO TOE

Head : Normocephaly

Eyes : Pupil circular, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, IndirectLight Reflex +/+, CA -

Ear : normal, LCS (-), blood (-)

Neck : Bruise (-), hematoma (-)

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Thorax :- Inspection : bruise (-), movement of chest wall

symmetrical

- Palpation : crepitation (-), palpation pain (-)

- Percussion : sonor right = left, percussion pain

(-)

- Auscultation: Basic breath sound Vesicular

right=left, wh-/-, rh-/-.

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Abdomen

- Inspection : flat, bruise (-),

- Auscultation : bowel sound (+) 8x/min

- Palpation : tenderness (-), defensemuscular (-)

- Percussion : tympani, percussion

pain (-)

S i E t iti

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Superior ExtremitiesRegio Cubiti Dextra

Look : Vulnus Excoriation (10 x 4 cm), blood (+),

active bleeding (-), oedem (-)Feel : Pain on palpation (+)

Movement : Active with no limitation

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Inferior Extremities

Regio Genu Dextra

Look : vulnus excoriation (5 x 3cm), blood (+), active

bleeding (-) , oedem (+)

Feel : pain on palpation (+)

Move : valrus + vagusnormal, Lachmans & Drawer

testnormal

Regio Genu Sinistra

Look : vulnus excoriation (2x1 cm), blood (+), activebleeding (-), oedem (-)

Feel : pain on palpation (+)

Move : valrus+vagusnormal, Lachmans&Drawer test

normal

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Regio Dorso Pedis Dextra

Look : Vulnus Excoriation

(3x1 cm), blood (+), active

bleeding (-), oedem (+)

Feel : pain on palpation (+)

Move : active with nolimitation

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Working diagnose

Multiple Vulnus Excoriation

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3. Child D

(6Years Old)13.85.05.00

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Chief complain

Pain on abdomen

Additional complain

-

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History of present illness:

Patient came to UKIs ER with her

family with complaint of pain on her

abdomen since 4 hours before

admission. Pain was sharpy andintermittent. According her parents,

she ate needle 12 hours before

admission. She could eat normally,vomit denied and she hadnt got

defecation.

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General Examination

GC : Look mildly sick

Consciousness: E4M6V5 GCS 15 pupil

circular, isochoric 3mm/3mm, centered,

DLR +/+, ILR +/+,Vital sign

BP : 100/60 mmHg

HR : 72 x/mnt

RR : 16 x/mnt

T : 36,2

C

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Thorax :Insp : movement of chest wall

symmetrical

Pal : vocal fremitus right = leftPer : sonor right = left, percussion pain (-)

Aus : Basic breath sound vesiculer

right=left

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Abdomen:Inspection: looks flat

Auscultation: bowel sounds 8x/m

Palpation: Defence muscular (-),tenderness (+)

Percussion: percussion pain (+)

Extremities: warm acral, crt < 2s

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Working Diagnosis

Korpus alineum in abdomen

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Abdomen BNO Xray23.00

(23 august 2014)

bd

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Abdomen Xray01.00

(24 August 2014)

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Diagnosis

Corpus Alineum Upper Right

Abdomen

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Treatment

Non Medicamentosa

Non Hospitalized

Education :

Observation acute abdomen sign at

home, if +bring to hospital

Eat Jelly or Papayas for stimulating

defecation

Medicamentosa