Morport 26 Feb 2014

8/12/2019 Morport 26 Feb 2014

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Emergency Room

Morning ReportSeptember, 23th 2012

1 patient non trauma2 patients trauma

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1. Mrs. S ( 42 YO)

Chief complain

Pain on right lower abdominal

Additional complain

-

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History of present illness:

Patient came to the hospital complaining pain ather right lower stomach. She has that pain 3 hours

before admitted. The pain felt like stabbed,

continously, and getting worsen. The pain camefirst when she got menstruation day 1 and she

always got pain at lower left and right stomach

but never get worsen like this time. The patient

has never got any medicine or went to the doctor

before. Nausea (-), Vomitus (-), Anorexia (-),

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Defecation normal, the patient got her last

defecation 6 hours before admitted, pain when

defecation (-), abnormal feces (-).

Taking a pee normal, the patient still had a clear

urine and no pain.

She had ever got to doctor before and she was

diagnosed having cyst at her left ovarium. But

she never take any treatment after dignosed.

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

symmetrical

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

Per : sonor right = left, percussion pain (-)

Aus : Basic breath sound vesiculer

right=left

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Abdomen :

Ins : flat, skin colour was the same.

Aus : bowel sound 5x/minute

Pal : pain on palpation (-), defence muscular (-)

Per : tympani, percussion pain (-)

Extremity :

Warm extremities, cap refill < 2”, edema (-).

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Diagnosis

Right Lower Abdomen Pain on Observation

Dd/ Ovarium Cyst

Chronic Appendicitis

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Treatment

• Non Medicamentosa

Patient went home

• Medicamentosa

Antibiotic

H2 Blocker

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2. Mrs. SA ( 65 YO)

Mechanism of the Trauma

Fell from the stairs

Injury of target organ

Vulnus excoriation at frontal lobe

Symptoms and signs

Pain

Transported by

Patient came with her family

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PRIMARY SURVEY

• Airway : No snoring, No gargling, No Stridor

Conclusion : CLEAR

• Breathing :

Insp : bruise -, chest wall movement symmetrical, RR

20 x/min, hematoma -

Pal : vocal fremitus simetrical right and left,

crepitation -

Per : sonor right = left

Aus : Basic breath sound bronchial, rh -/-, wh -/-

Conclusion : No pneumothorax, no hemothorax

CLEAR

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• Circulation

– warm extremities, Pulse = 80 bpm, Temp= 36,50C,

capillary refill <2” Conclusion : No sign of shock

• Disability – GCS 15 (E4M6V5) pupil isochoric 3/3 mm,

centered,

– direct light reflex/indirect light reflex +/+

• Exposure

There is no life threatening wounds

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AMPLE

• Allergy : -

• Medication : -

• Past Illness : -

• Last Meal : 3 hours before admittion

• Event : Fell from stairs

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Secondary Survey

• Chief complaint : wound at head after fell

from the stairs

• Additional complaint : -

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History of Illness

Patient came to the hospital after fell from the

stairs at her house 2 hours before admitted.

She got a wound at her head and she felt pain.

She was walking upstairs and fell at about 2

meters high. After fell the patient still could

walk. The pain felt not continously. Headache (-

), Vertigo (-), Nausea (+), Vomitus (+),Unconciussness (-)

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HEAD TO TOE

Head : Regio Frontalis dextra

L : open wound, dirty, basic skin, 3x1 cm ,bleeding (-)

F : crepitation (-)

Eyes : Pupil circular, isochoric 3mm/3mm,centered, Direct Light Reflex +/+, Indirect

Light Reflex +/+

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

Neck : Bruise (-), hematom (-)

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

symmetrical

Pal : crepitation (-), palpation pain (-) Per : sonor right = left, percussion pain (-)

Aus : Basic breath sound bronchial

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

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Abdomen :

Ins : flat, bruise (-), muscular defense (-)

Aus : bowel sound (+) 5x/min

Pal : tenderness (-)


Extremity :


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Clinical foto

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Working diagnose

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TREATMENT

• Non Medicamentosa :

Hospitalized• Medicamentosa :

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3. Mr. HBP ( 50 YO)

Mechanism of the Trauma

wound at right hand because of a slice of mirror

Injury of target organ

Vulnus laceration of antebrachii dextra

Symptoms and signs

Pain

Transported by

Patient came with his wife

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PRIMARY SURVEY

• Airway : No snoring, No gargling, No Stridor

Conclusion : CLEAR

• Breathing :

Insp : bruise -, chest wall movement symmetrical, RR

16 x/min, hematoma -

Pal : vocal fremitus simetrical right and left,

crepitation -

Per : sonor right = left

Aus : Basic breath sound bronchial, rh -/-, wh -/-

Conclusion : No pneumothorax, no hemothorax

CLEAR

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• Circulation

– warm extremities, Pulse = 60 bpm, Temp= 36,90C,

capillary refill <2” Conclusion : No sign of shock

• Disability – GCS 15 (E4M6V5) pupil isochoric 3/3 mm,

centered,

– direct light reflex/indirect light reflex +/+

• Exposure

There is no life threatening wounds

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AMPLE

• Allergy : -

• Medication : -

• Past Illness : -

• Last Meal : 3 hours before admittion

• Event : Hand got a slice of mirror

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Secondary Survey

• Chief complaint : wound at right hand after

got a slice of mirror

• Additional complaint : -

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History of Illness

Patient came to the hospital after his right hand

got a slice of mirror 2 hours before admitted. He

was repairing the mirror when suddenly the

mirror fell and then his hand touched the mirroruntil got wound. He got a wound at her head and

he felt pain. After fell the patient still could

move his hand free. The pain felt notcontinously. Headache (-), Vertigo (-), Nausea

(+), Vomitus (+), Unconciussness (-)

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Abdomen :

Ins : flat, bruise (-), muscular defense (-)

Aus : bowel sound (+) 5x/min

Pal : tenderness (-)


Extremity :


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Clinical foto

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Morport 26 Feb 2014

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