morpot kita.pptx

8/13/2019 morpot kita.pptx

1/17

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Morning Shift Reportst 2013


2/17

Ms. T ( 25 YO)

M : the left toe crushed by car

I : regio pedis sinistra digiti I

S : pain

T : motorcycle


3/17

Primary Survey

Airway : Clear Breathing :

Insp : bruise (-), chest wall movement

symmetrical, RR 24 x/ min, hematoma (-) Pal : crepitation sub cutis (-)

Per : sonor right = left

Aus : Basic breath sound vesicular right = left


4/17

C = warm extremities, Pulse = 100bpm, BP 130/90 mmHg,

capillary refill time


5/17

History of illness :

Patient came to RSU UKI with the chief complainpain on the left toe. According to the patient,

the pain felt like tingling. Patient was hit by a car

when she walked to cross the street. Her left toewas pinned down under the car tires for about 1

minute. Patient was taken to RS UKI

immediately.


6/17

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 (-)



SECONDARY SURVEY


7/17

Abdomen :

Ins : flat, bruise (-)

Aus : bowel sound (+) 6x/min

Pal : Supel, tenderness (-), muscular

defense (-)

Per : tympani

Extremity:

Warm extremities, cap. refill time < 2,

edema (-)


8/17

Localized StatusRegio Pedis Sinistra Digiti I

Look : vulnus excoriation 2x1cm, active bleeding (-),

cyanosis (+), the nail almost loose Feel : tenderness (+), edema (-)

Move : active (+) passive (+)


9/17


10/17

Diagnosis

Closed fracture phalang distal digiti I pedis

sinistra nondisplaced


11/17

TREATMENTWound toilet

Extraction of the nail

AntibioticAnalgetic

Antagonist H2 receptor


12/17

Ms. M (51YO)Chief complaint : pain on the

Additional complaints :


13/17

History of illness :

Patient came to the RSU UKI with chief complain

pain in wound trace of operation. The operation,appendectomy was done on 1st June 2013.According to her the pain felt like tingling. The

patient felt more pain when she walked. Pus (-),

blood (-), stich scar good. The pain was spread

until the back. Theres no problem with the

urinate and defecation.


14/17

General StatusGeneral Condition : Mild Illness AppearanceGCS : E4V5M6

BP : 110/70 mmHg

Pulse : 68 bpm

Temp : 36, 3RR : 18 x/min

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 (-)




15/17

Abdomen :

Ins : flat, bruise (-)

Aus : bowel sound (+) 8x/min

Pal : Supel, tenderness (+), muscular defense (-)

Per : tympani

Extremity:

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


16/17

DiagnosisPost appendectomy e.c appendicitis chronic

Lower right abdomen pain e.c susp. UTI


17/17

TreatmentAnalgetic

Vitamin B12

Antagonist H2 receptor

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morpot kita.pptx