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Emergency Room

Morning Shift ReportMay , 31st 2013

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Mr. G ( 25 YO)

M : motor cycle accident

I : regio dorso manus dextra and sinistra

S : vulnus eksoriasi et dorso manus dextra and

sinistra, patela dextra

T : -

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Primary Survey Airway : Clear Breathing :

Insp : bruise (-), chest wall movement

symmetrical, RR 18 x/ min, hematoma (-) Pal : crepitation sub cutis (-)

Per : sonor right = left

Aus : Basic breath sound vesicular right = left

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C = warm extremities, Pulse = 88bpm, BP 110/70 mmHg,

capillary refill time

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History of illness :

Patient came to the RSU UKI with police because the

patient had a traffic accident. The patient fell down

from his motor cycle with the left arm as a . After he

fell there was no active bleeding, no loss of

consciousness, no vomitting, theres no head injury.

Patient can talk coherently in long sentence and walkby himself to the hospital. Patient already went to the

clinic and has been given medication to heal his

headache.

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HEAD TO TOE

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

reflex/ indirect light reflex +/+

Ear : Bruise (-), hematoma (-)

Neck : Bruise (-), hematoma (-)

Thorax :

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

Pal : crepitation (-), tenderness (-)

Per : sonor right = left

Aus : Basic breath sound vesicular right = left

SECONDARY SURVEY

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Abdomen :

Ins : flat, bruise (-)

Aus : bowel sound (+) 6x/min

Pal : Supel, tenderness (-), muscular

defense (-)

Per : tympani

Extremity:

Warm extremities, cap. refill time < 2,

edema (-)

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Localized StatusRegio Manus Dextra

Insp : bruise (+), active bleeding (-)

Pal : crepitation (-), tenderness (-)

Move : can palmar flexion, dorso flexion, ulnar

flexion, radier

Regio Manus Sinistra Insp : bruise (+), active bleeding (-), oedem (+)

Pal : crepitation (-), tenderness (+)

Move : cant palmar flexion, dorso flexion, ulnar

flexion, radier

Regio Genu Dextra Insp : bruise (+), active bleeding (-)

Pal : crepitation (-), tenderness (-)

Move : can palmar flexion, dorso flexion, ulnar

flexion, radier

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Diagnosis

Fr. Os radius sinistra intra artikular tertutup

tanpa gangguan NVD

Vulnus Eksoriasis dorso manus dextra-sinistra, dan patela dextra

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TREATMENT Sporetik 2x100 mg

Analgetik 3x1

Oscal 2x1 Tab