Night Shift Report: Emergency Unit
Night Shift Report: Emergency Unit
Night Shift Report: Emergency Unit
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
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
Thorax :
- Inspection
Abdomen
-
Inspection
Auscultation
Palpation
Percussion
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
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
Abdomen
- Inspection
- Auscultation
- Palpation
- Percussion
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
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
-
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:
Working Diagnosis
Korpus alineum in abdomen
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