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Emergency Room

Morning Shift ReportMay, 17th 2013

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1. Mr.J (63 YO)

M : Falling from a bycycle

I : head

S : wound

T : -

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Primary Survey

Airway : snoring -, gurgling -, stridor

Clear

Breathing :

Insp : bruise (-), chest wall movementsymmetrical, RR 20 x/ min, hematoma (-)

Pal : tenderness (-)

Per : sonor right = left

Aus : Basic breath sound vesicular

rh-/- wh -/-

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C = warm extremities, Pulse = 96bpm, BP

120/80 mmHg, Temp = 36,3C, capillary

refill time

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History of illness :Patients come to the RSU UKI due to a fall from a

bycycle 1 hour ago before coming to the hospital.

Patients bycycle hit by motorcycle from behind.

Patient fall and his head hit the asphalt. Patient

realized his head was cut and bleeding. Patient canrecall the events before and after accident. Head

impact (+), abdominal impact (-) vomiting (-), nausea (-

), unconsciousness (-), headache (+)

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HEAD TO TOE

Eyes : pupil isochors 3mm/3 mm, centered, direct light

reflex/ indirect light reflex +/+, hematoma (-/-)

Ear : Bruise (-), hematoma (-)

Neck : Bruise (-), hematoma (-)

Thorax :

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

Pal : crepitation sub cutis (-), tenderness (-)



SECONDARY SURVEY

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Abdomen :

Ins : flat, bruise (-)

Aus : bowel sound (+) 4x/min

Pal : Supel, tenderness (-), musculardefense (-)

Per : tympani

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Status localized

Regio parietal

L : vulnus laseratum 7x2x1cm,basic soft

tissue,eneven edges,clear boundary,

massive bleeding (-)F : tenderness (+), crepitation (-),

M: (-)

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Ample

Allergic :-

Medication : -

Past illness:-

Last meal : 4 hour before come to

UGD RS UKI

Event : fall from bycycle

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Diagnosa

Mild head injury + vulnus laseratum

regio parietalis sinistra

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Treatment

Wound toilet

Hecting regio parietalis sinistra

mm/: - antibiotic- dexoketrofen

- Vit B complex

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Mr. D (23)

M : Falling from a motorcycle

I : extremity

S : wound

T : -

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Primary survey

Airway : snoring -, gurgling -, stridor

Clear

Breathing :

Insp : bruise (-), chest wall movementsymmetrical, RR 20 x/ min, hematoma (-)

Pal : tenderness (-)



rh-/- wh -/-

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C = warm extremities, Pulse = 90bpm, BP

110/70 mmHg, Temp = 36,3C, capillary

refill time

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History of illness

Patients come to the RSU UKI due to a fall from a

motorcycle 2 hour ago before coming to the hospital.

Patient riding a motorcycle at speeds 60km/hour, and he

use half face helmet.Patients motorcycle avoid some holes

and patient fall and his right body hit the pole. Patient can

recall the events before and after accident. Head impact (-

), abdominal impact (-) vomiting (-), nausea (-),

unconsciousness (-), headache (-)

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Secondary survey

HEAD TO TOE

Eyes : pupil isochors 3mm/3 mm,

centered, direct light reflex/ indirect light reflex

+/+, hematoma (-/-)

Ear : Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-)

Thorax :

Insp : bruise (-), movement of chest wall

symmetrical Pal : crepitation sub cutis (-), tenderness (-)



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Abdomen :



Pal : Supel, tenderness (-), musculardefense (-)

Per : tympani

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Status Localized

Regio manus sinistra digiti II

L: vulnus excoriation 2x2cm ,

edema (-)

F: crepitation (-), tenderness (+)

M : adduction

abduction

Regio tibialis anterior

dextra

L: vulnus excoriation 2x3 cm,

edema (-)

F: crepitation (-), tenderness

(+)

M : flexion

extention

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Regio interphalax pedis

dextra digiti II-III

L : vulnus scissum 4x5x2cm,

basic soft tissue, eneven

edges,clear boundary,

massive bleeding (-)

F : crepitation (-), terderness

(+)

M: adduction

abduction

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Ample

Allergic :-

Medication : -

Past illness:-

Last meal : 3 hour before come to UGDRS UKI

Event : fall from motorcycle

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Diagnosa

Soft tissue injury regio interphalax

pedis dextra digiti II-III + vulnus

exoruation regio manus dextra

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Treatment

Wound toilet

Hecting regio interphalax pedis

dextra digiti II-III

Unhospitalized

Mm/: antibiotic

dextoketrofenvit c

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Mrs S (85 YO)

Chief complain :

- fall by her self

Additional complain :

- pain of spine, and hip

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History of illness :

Patient came to IGD RSU UKI with complaintsfall by her self in sit position. Patient felt pain at

her spine and her hip. Patient walk with help

from cane. Patient also complaint heartburn and

nausea. Patient has hipertention history (+), DM(+), hyperuresemia (+).urinating disorder (-)

Defecate disorder (-).

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Allergic : -

Medication : nifedipine

Past illness : hipertention since 10

years ago, DM (+),hyperuresemia (+)

Last meal : 4 hour before coming to

hospital

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Status Generalis

BP : 160/90mmhg

Pulse : 98 bpm

RR : 20 x/minutes

Temp. : 36,3c

GCS : E4M6V5

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Secondary survey

HEAD TO TOE Eyes : pupil isochors 3mm/3 mm, centered, direct light

reflex/ indirect light reflex +/+, hematoma (-/-), conjuctiva

anemis (+/+)

Ear : Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-)

Thorax :

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

Pal : crepitation sub cutis (-), tenderness (-)



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Abdomen :



Pal : Supel, tenderness (-), muscular defense

(-)

Per : tympani

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Regio vertebrae

L: bruise (-), deformity (-)

F: terderness lumbar area (+) , crepitation (-),

M: left lateral flexi

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Ekstremitas :

Warm extremity

Capp reffil

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Diagnosis

suspect fracture compretion vertebrae

L4-L5

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Treatment

unhospitalized

Mm/ : analgesic

calcium

ranitidine

Documents

morpot 050513.pptx