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    Morning Shift Report: Emergency Room

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    alfonsinacp
    1. A 40-year-old man fell from a ladder into a pool, hitting his head on the wall of the pool. He experienced pain in the back of his head but was conscious and coherent after the fall. 2. An examination in the emergency room found bruising on the back of his head but no other injuries. Vitals and neurological functions were normal. 3. A CT scan and ECG were performed, and the patient was diagnosed with a mild head injury. He was given analgesics and vitamins to treat the injury and pain.

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    Morning Shift Report: Emergency Room

    Uploaded by

    alfonsinacp
    31 views12 pages
    1. A 40-year-old man fell from a ladder into a pool, hitting his head on the wall of the pool. He experienced pain in the back of his head but was conscious and coherent after the fall. 2. An examination in the emergency room found bruising on the back of his head but no other injuries. Vitals and neurological functions were normal. 3. A CT scan and ECG were performed, and the patient was diagnosed with a mild head injury. He was given analgesics and vitamins to treat the injury and pain.

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    1. A 40-year-old man fell from a ladder into a pool, hitting his head on the wall of the pool. He experienced pain in the back of his head but was conscious and coherent after the fall. 2. An examination in the emergency room found bruising on the back of his head but no other injuries. Vitals and neurological functions were normal. 3. A CT scan and ECG were performed, and the patient was diagnosed with a mild head injury. He was given analgesics and vitamins to treat the injury and pain.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    31 views12 pages

    Morning Shift Report: Emergency Room

    Uploaded by

    alfonsinacp
    1. A 40-year-old man fell from a ladder into a pool, hitting his head on the wall of the pool. He experienced pain in the back of his head but was conscious and coherent after the fall. 2. An examination in the emergency room found bruising on the back of his head but no other injuries. Vitals and neurological functions were normal. 3. A CT scan and ECG were performed, and the patient was diagnosed with a mild head injury. He was given analgesics and vitamins to treat the injury and pain.

    Copyright:

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    Download as PPT, PDF, TXT or read online from Scribd
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    You are on page 1of 12

    Emergency Room

    Morning Shift Report


    May , 31st 2013

    Mr. I (40 YO)


    M : fall from the ladder into the pool I : back of the head (regio occipital dextra) S : pain T : already went to the clinic and was given medication to heal the pain of his head

    Primary Survey
    Airway : Clear Breathing : Insp: bruise (-), chest wall movement symmetrical, RR 18 x/ min, hematoma (-) Pal: crepitation sub cutis (-) Per : sonor right = left Aus : Basic breath sound vesicular right = left

    C = warm extremities, Pulse = 88 bpm, BP 110/70 mmHg, capillary refill time <2 D = GCS E4M6V5, pupil isochors 3mm/3mm, centered, direct light reflex/ indirect light reflex +/+ E = there is no life threatening wound

    History of illness :
    Patient came to the RSU UKI due to fell from the ladder into the pool about 6 hours before came to the hospital. The height of the ladder to the pool is about 2 meters. The affected area is on the back of his head (right part). The patient got electric shock before he fell. When he fell, his head was hit to the wall of the pool. At that time, hes awake and tried to get up from the pool. After he fell there was no active bleeding, no loss of consciousness, no vomitting, but he felt pain at the head which is hit. There is no impact in the other part of body. Patient can talk coherently in long sentence and walk by himself to the hospital. Patient already went to the clinic and has been given medication to heal his headache.

    SECONDARY SURVEY
    HEAD TO TOE
    Eyes: pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+ Ear: Bruise (-), hematoma (-) Neck: Bruise (-), hematoma (-) Thorax: Insp : bruise (-), movement of chest wall symmetrical Pal : crepitation (-), tenderness (-) Per : sonor right = left Aus: Basic breath sound vesicular right = left

    Abdomen : Ins: flat, bruise (-) Aus: bowel sound (+) 6x/min Pal: Supel, tenderness (-), muscular defense (-) Per: tympani Extremity: Warm extremities, cap. refill time < 2, edema (-)

    Localized Status
    Regio occipital dextra
    Insp : bruise (-), active bleeding (-) Pal : crepitation (-), tenderness (-)

    CT Scan

    ECG

    Diagnosis
    Mild head injury

    TREATMENT
    Analgetic Vitamin B complex

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