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Emergency Unit

Night Shift ReportDecember 16th2014

Assistant: dr. Hendy/dr. Benny

Co-assistant:

Dian Nur Martika A

Glen Jacobs S

Leonard Evan M

Kharisma Pertiwi

Riya Hanaza RNadia Latifa D

Dyah Anjani K.S

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Trauma: 1

Non-Trauma: 2

Hospitalize: 3

Non-Hospitalize: -

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1. Ms. W (73 years old)

Main complaint : bleeding from

mammae dextra

Secondary complaint : -

Pre hospital treatment : tampon on

dextra mammae, analgetic, vit K

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History of illness

Patient came to ERS RSU UKI with main complaint

bleeding from mammae dextra 3 days ago. Bleeding a

lot continously. In Sept 2014 patient went to

RS.Dharmais to consultation about mass in breast.

Diagnose from RS. Darmais was mammae cancer butshe and her family denied to get chemotherapy. She has

been got some medication like analgetic, vit K, and

tampon on dextra mammae.

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Vital Sign

General conditions : look severe sick

consciousness: GCS E3 V2 M5

BP : 110/70mmHg Pulse: 84x/menit

RR: 22 x/menit

temperature : 36,4 oC

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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 (-)

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

symmetrical

- Palpation : -

- Percussion : -

- Auscultation : basic breath sound vesicular

left, wh-/-, rh-/-.

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Abdomen :

- Inspection : flat, bulging (-)

- Auscultation : bowel sound (+) 8x/min

-Palpation : tenderness (-), defense muscular

(-), pain palpitation (-)

- Percussion : tympani, percussion pain (-)

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Extremities

CRT

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Locale status

mammae :

I :mass diameter : 13cm Thick : 5 cm,

ulcus +, pus +, active bleeding

Pal : -

Per : -

A: basic breath sound vesicularleft, wh-/-, rh-/-.

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Laboratorium 16/12/14

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Working diagnose

Ca Mammae dextra T4bNXM1

Anemia

Hiponatremia

Hipoklorinemia

hipoalbuminemia

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TREATMENT

Non-Medicamentosa:Hospitalize

Diet : high protein high karbohidrat

NGT

IVFD : I Nacl 3%, II futrolit, I RL(24 hours)

PRC 300cc Hb: 9 g/dl

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Medicamentosa :

Levofloxacin1x500mg (IV)

Paracetamol

Ca Gluconas 1 amp (IV)

Vit K 1 amp (IV)

Plasminex 2X1 amp (IV)

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2. Mr. O (43 years old)

Main complaint : pain in his genitalia

Secondary complaint : -

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History of illness

Patient came to ERS RSU UKI with main complaint

pain in his scrotum since 2 weeks ago. The pain can be

felt when patient on sit position and the scrotum was

touched. Patient didntknow caused from his complaint,

only the pain came suddenly. The pain isntcontinously

sometimes come and then not pain anymore. The pain

had not been cured before. Patient didnthave complaint

like this before and never used some drugs to reduced

his complaint.Family history : Diabetic Melitus

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Vital Sign

General conditions : Look mild sick

Consciousness: E4V5M6

BP : 120/90mmHg

Pulse: 102x/minute

RR: 22 x/minute

Temperature : 36,3o

C

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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 (-)

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symmetrical

- Palpation : Vocal fremitus symmetrical

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

- Auscultation : basic breath sound vesicular

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

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Abdomen :

- Inspection : flat, bulging (-)


-Palpation : tenderness (-), defense muscular

(-), pain palpitation (-)

- Percussion : tympani, percussion pain (-)

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Extremities

CRT< 2, warm, sensoric (+)

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Locale status

Genitalia externa

Penis :

OUE : secret -, stricture -,

circumcision-, pain-,

Scrotum :

I : swelling (+) hyperemis (+), pus (+)Palpation : pain (+), dextra testis not

palpable,

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Laboratorium

Na : 130 mmol/L

K : 4,1 mmol/L

Cl : 96 mmol/L

Hb : 11,6 gr/dl

L : 11.700/ul

Ht : 32,3 % T : 347.000/ul

GDS : 453mg/dl

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Urinalisa

Reduction +3

Leucocyt 4-6/LPB

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Working diagnose

Abses Regio

scrotalis

DM type 2

Hiponatremia Anemia

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Treatment Planning

Diet : biasa

IVFD

I RL

Medikamentosa Ceftriaxone 1 gr

(IV)

Tofadex 3 X 1

amp (IV)

Ranitidine 2 X 1

amp (IV)

Kompres luka

dengan Nacl

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TN. A ( 54th)Mechanism of the Trauma

Patient fell from motorcycle due to abrupt stop because

the car in front of him sudden break. Patient fell left

sided so the bike he ride fall on him.

Injury of target organ

Extremities

Symptoms and signs

Pain, wound, edema

Treatment Pre Hospital (-)

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PRIMARY SURVEY

Airway : CLEAR

Look : no obstruction

Listen : no extra breath sound (gurgling (-), snoring (-),

stridor (-)) Feel : there were warm air from both nose and mouth

Breathing : CLEAR

Inspection: bruise (-), chest wall movement

symmetrical, RR 18 x/min, hematoma ()

Pal : crepitation (-)

Per : sonor right = left

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

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Circulation : No Sign Of Shock

Warm extremities

Blood pressure 120/80 mmHg

Pulse = 108 x/minute

Temp =36 0C

CRT

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SECONDARY SURVEY

AMPLE

Allergy : -

Medication : - Past Illness : -

Last Meal : in the evening

Event : Accident

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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 (-)

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symmetrical

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

- Percussion : sonor right = left, percussion pain

(-)

- Auscultation: vesicular basic breathe sound

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

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Abdomen

- Inspection : flat, bruise (-),


-Palpation : tenderness (-),muscular

defense (-)

- Percussion : tympani, percussion

pain (-)

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Locale status

L : multiple lesion, swollen,

F : crepitate, pain

M : he cant lift his left leg, finger

movement (+)

CRT< 2, warm, sensoric (+)

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History of illness

Patient brought to hospitals emergency unitbecause a motorcycle accident about an hour

before arrive at hospital. He got scratches on his

left and right palm, and his left and right lower

leg. He also have difficulty to move his leg. Thereis an open wound on his right fourth finger and

left knee. He didnt have any complain for

dizziness, feeling sick or vomiting.

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Lab

Hemoglobin 13.4 g/dl

Leukocyte 15.200 /uL

Hematocrite 40,1 %

Trombocyte 269.000 /uL

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X-RAY

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Working diagnosis

Close fracture intraarticular os tibia sinistra

without NVD

Multiple vulnus excoriasi

Multiple vulnus laceration

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TREATMENT Non Medicamentosa :

- Hospitalized pro ORIF

- Wound toilet

- Diet : Biasa

- IVFD : I RL + III amp KetorolacMedicamentosa :

- Ceftriaxone 2x1 gram

- ranitidin 2x1

Documents

MORPOT 17.12.14