Emergency Unit

Night Shift ReportMarch, 25th 2014

Assistant:Dr. Hendy S

Co-assistant:Princessa S(chief)

Hizkia DOcha Poetra

DeviTiur

Melati Indriana

1. Ms. J (23 Years Old)MR. 18.42.05.00

Mechanism of the Traumaworking accidentInjury of target organPalmaris manus sinistra Symptoms and signs Pain on palmaris manus sinistrableedingTreatment Pre Hospital (Before UKI’S ER)-

PRIMARY SURVEY • Airway

– Look : no obstruction– Listen : no extra breath sound (no gurgling, no snoring, no stridor, no horseness)– Feel : there were warm air from both nose and mouth– Conclusion : CLEAR

• Breathing– Inspection: bruise (-), chest wall movement symmetrical,

RR 21 x/min, hematoma (–)– Palpation : crepitation (-)– Percussion: sonor right = left– Auscultation: Basic breath sound vesicular, rh -/-, wh -/-– Conclusion : CLEAR

• Circulation – Warm extremities,– Pulse = 92 x/min– BP = 120/80 mmHg– Temp= 36.4 0C– RR = 21 x/min– CRT <2”– Conclusion : No Sign Of Shock

• Disability– GCS 15 (E4M6V5) pupil isochoric 3/3 mm, centered, – Direct light reflex +/+ , indirect light reflex +/+

• Exposure There’s no life threatening wounds on regio manus sinistra

Secondary Survey

• Chief complaint : pain on regio manus sinistra• Additional Complaint : bleeding

History of illness

A patient came accompanied with his friends to UKI’s E.R because of an accident in the working place 1 hour ago. He felt pain on the left hand because get drilled. No vomitus, bleeding on regio palmaris manus sinistra, oedem on regio dorsum sinistra (+).

HEAD TO TOEHead : NormocephalyEyes : Pupil circular, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect

Light Reflex +/+, CA +/+ , right sclera hematoma (+)

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

Neck : Bruise (-), hematoma (-)

1. Vulnus punctum on regio palmaris manus sinistrasize : ± 0,3 x 0.3 cm

• Superior ExtremitiesLook : Vulnus punctum on regio palmaris

manus sinistra size : ± 0,3 x 0.3 cm, oedem (+), hematoma (-), bleeding on (+) rotation (-)Feel : Warm, CRT <2”, pain on palpation (-), crepitation (-)Movement : able to move gently Motoric ++++/++++Sensoric ++++/++++

• Inferior ExtremitiesLook: edema (-), hematoma (-), rotation (-)Feel: pain on palpation (-), crepitation (-)Movement : able to move gently

sensoric ++++/++++motoric ++++/++++

AMPLE

• Allergy : - • Medication : -• Past Illness : -• Last Meal : -• Event : Working Accident

Working diagnose

Vulnus Punctum on regio palmaris pedis sinistra

TREATMENT

•Non Medicamentosa :– Cross Incisi– Debridement

•Medicamentosa :– Sporetic 2 x 100mg – Acran 2 x 1– Ketesse 3 x 1

2. Ms. L (17 Years Old)MR. 56.41.05.00

Mechanism of the TraumaTraffic accidentInjury of target organMaxilla dextra, sclera dextra, and superior lipSymptoms and signs Pain on maxilla dextra, headache, and nauseaTreatment Pre Hospital (Before UKI’S ER)-

PRIMARY SURVEY • Airway

– Look : no obstruction– Listen : no extra breath sound (no gurgling, no snoring, no stridor, no horseness)– Feel : there were warm air from both nose and mouth– Conclusion : CLEAR

• Breathing– Inspection: bruise (-), chest wall movement symmetrical,

RR x/min, hematoma (–)– Palpation : crepitation (-)– Percussion: sonor right = left– Auscultation: Basic breath sound vesicular, rh -/-, wh -/-– Conclusion : CLEAR

• Circulation – Warm extremities,– Pulse = x/min– BP = mmHg– Temp= 36.5 0C– RR = x/min– CRT <2”– Conclusion : No Sign Of Shock

• Disability– GCS 15 (E4M6V5) pupil isochoric 3/3 mm, centered, – Direct light reflex +/+ , indirect light reflex +/+

• Exposure There was no life threatening wounds.

Secondary Survey

• Chief complaint : pain on the head and thorax • Additional Complaint: headache, nausea

History of illness

A patient came accompanied with train officer to UKI’s E.R because of an accident in the train station at twenty minutes ago. She was fainted for few minutes. The patient doesn’t know how was the accident happening. She felt pain on the right cheek, headache, and nausea. Projectile vomit (-), massive bleeding (-), edema (-).

HEAD TO TOEHead : NormocephalyEyes : Pupil circular, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect Light Reflex +/+, CA +/+ , right sclera

hematoma (+)Ear : normal, LCS (-), bleeding (-), blood spot (-)Neck : Bruise (-), hematoma (-)

1. Vulnus excoriation on regio maxillofacial (size : 7 x 4 cm), superior (size : 0.8 x 0.3 cm)2. Edema on the regio maxillofacial

• Superior ExtremitiesLook : Edema (-), hematoma (-), massive bleeding (-) rotation (-)Feel : Warm, CRT <2”, pain on palpation (-), crepitation (-)Movement : able to move gently Motoric (++++)Sensoric (++++)

• Inferior ExtremitiesLook: edema (-), hematoma (-), rotation (-)Feel: pain on palpation (-), crepitation (-)Movement : able to move gently

sensoric (++++)motoric (++++)

X-ray schedel

X-ray cervical

AMPLE

• Allergy : - • Medication : -• Past Illness : -• Last Meal : rice and chicken at 7 am• Event : Traffic Accident

Working diagnose

Mild Head Injury + Vulnus excoriation with edema on maxillofacial + vulnus ulceration

on superior lip + right sclera hematoma

TREATMENT

•Non Medicamentosa :Reposition, hospitalized

•Medicamentosa :– RL + Ikaneuron 1 amp, Ergotika 2 amp– RL + Ketesse 3 amp