Night Shift Report: Emergency Unit

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Emergency Unit

Night Shift Report


August, 23rd 2014
Assistant:
dr. Hendy
Co-assistant:
Melissa Ronaldi ( Chief)
Novena
Etriansa Widiens Orno
Anastasia F
Michael
Cynthia Dasuki
Zega Agustian

Trauma: 2
Non Trauma: 1

Hospitalize: 1
Non Hospitalize: 2

1. Boy I
(13 Years Old)
04.85.05.00
TAC : 16.00 (August, 22 2014)
TAR: 13.00 ( August 23, 2014)

PRIMARY SURVEY

Airway snoring (+) Guedel clear


Breathing : CLEAR
Circulation :N: 120 bpm TD 130/70 mmHg
Disabillity GCS E2V2M5 pupil anisokor D >S
Exposure: threre was no life threatening wounds

Secondary Survey
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event

:::: yesterday
: accident

History of illness
Patient came to the ER with the complaints of
loss 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 UKIs
ER. Patient had fever and seizures.

HEAD TO TOE

Head : bruise (+)


Regio frontozygomatica
dextra
Look : vulnus excoriation (18
x 5 cm), blood (+), active
bleeding (-), oedem (+)
Feel : crepitation (-)

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


centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA Regio infra orbita dextra
Look : bruise (+), oedem (+), blood (-), active
bleeding (-)
Feel :crepitation (-)
Ear : normal, LCS (-), blood (-)
Neck : Bruise (-), hematoma (-)

Thorax :
- Inspection

: bruise (-), movement of chest wall


symmetrical
- Palpation : not doing
- Percussion : sonor
- Auscultation: Basic breath sound Vesicular
right=left, wh-/-, rh-/-.

Abdomen
-

Inspection
Auscultation
Palpation
Percussion

: flat, bruise (-),


: bowel sound (+) 6x/min
: defense muscular (-)
: tympani

Extremities
warm acral, capillary refill time <2 seconds,
oedem (-)

Working Diagnosis
Severe Head Injury susp Intracranial
Bleeding
Vulnus excoriation regio frontozygomatica
dextra

CT Scan

Cervical Rontgen

Chest X-Ray

Diagnosis
Severe Head Injury
Impression Fracture frontal dextra
Vulnus Excoriation frontozygomatica
dextra

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)

16.30
Patient went under supervision and
GCS decrease E1V1M4 intubation

17.30
Patient went to operating theater to
perform craniotomy found dura
laseration Craniotomy +
Duraplasty

2. Mrs. L
(51 Years Old)
15.78.05.00

PRIMARY SURVEY

Airway : CLEAR
Breathing : RR= 18 x/minute CLEAR
Circulation : BP = 150/90, HR= 92x/minute
Disability : GCS 15 E4M6V5
Exposure : There was no life threatening wounds

AMPLE

Allergy
Medication
Past Illness
Last Meal
Event

:::: in the afternoon


: accident

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. Patient
rode 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. Then
patient was brought to UKIs ER without any
treatment.

SECONDARY SURVEY
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA Ear : normal, LCS (-), blood (-)
Neck : Bruise (-), hematoma (-)

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-/-.

Abdomen
- Inspection
- Auscultation
- Palpation
- Percussion

: flat, bruise (-),


: bowel sound (+) 8x/min
: tenderness (-), defense
muscular (-)
: tympani, percussion
pain (-)

Superior Extremities
Regio Cubiti Dextra
Look : Vulnus Excoriation (10 x 4 cm), blood (+),
active bleeding (-), oedem (-)
Feel : Pain on palpation (+)
Movement : Active with no limitation

Inferior Extremities
Regio Genu Dextra
Look : vulnus excoriation (5 x 3cm), blood (+), active
bleeding (-) , oedem (+)
Feel : pain on palpation (+)
Move : valrus + vagus normal, Lachmans & Drawer
test normal
Regio Genu Sinistra
Look : vulnus excoriation (2x1 cm), blood (+), active
bleeding (-), oedem (-)
Feel : pain on palpation (+)
Move : valrus+vagus normal, Lachmans&Drawer test
normal

Regio Dorso Pedis Dextra


Look : Vulnus Excoriation
(3x1 cm), blood (+), active
bleeding (-), oedem (+)
Feel : pain on palpation (+)
Move : active with no
limitation

Working diagnose
Multiple Vulnus Excoriation

TREATMENT
Non Medicamentosa :
- Wound Toilet
Medicamentosa :
Cefixime 2x200 mg
Mefenamic Acid 3x500mg
Omeprazole 2x1 tab

3. Child D
(6 Years Old)
13.85.05.00

Chief complain
Pain on abdomen

Additional complain
-

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 and
intermittent. According her parents,
she ate needle 12 hours before
admission. She could eat normally,
vomit denied and she hadnt got
defecation.

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
: 36,2C

Thorax :
Insp : movement of chest wall
symmetrical
Pal : vocal fremitus right = left
Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound vesiculer
right=left

Abdomen:
Inspection: looks flat
Auscultation: bowel sounds 8x/m
Palpation: Defence muscular (-),
tenderness (+)
Percussion: percussion pain (+)

Extremities:

warm acral, crt < 2s

Working Diagnosis
Korpus alineum in abdomen

Abdomen BNO Xray 23.00


(23 august 2014)

Abdomen Xray 01.00


(24 August 2014)

Diagnosis
Corpus Alineum Upper Right
Abdomen

Treatment
Non Medicamentosa
Non Hospitalized
Education :
Observation acute abdomen sign at
home, if + bring to hospital
Eat Jelly or Papayas for stimulating
defecation
Medicamentosa
Amoxicilin Syrp 3xI

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