Emergency Room

Morning Shift Report

May, 17th 2013

1. Mr.J (63 YO)

M : Falling from a bycycle I : head S : wound T:-

Primary Survey
Airway : snoring -, gurgling -, stridor Clear Breathing :
Insp : bruise (-), chest wall movement symmetrical, RR 20 x/ min, hematoma (-) Pal : tenderness (-) Per : sonor right = left Aus : Basic breath sound vesicular rh-/- wh -/-

 C = warm extremities, Pulse = 96bpm, BP 120/80 mmHg, Temp = 36,3C, capillary refill time <2
Shock (-)

D = GCS E4M6V5, pupil isochors 3 mm/ 3 mm, centered, direct light reflex/indirect light reflex +/+ E = there is no life threatening wound

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 can recall the events before and after accident. Head impact (+), abdominal impact (-) vomiting (-), nausea (), unconsciousness (-), headache (+)

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 (-) Per : sonor right = left Aus : Basic breath sound vesicular

 Abdomen : Ins : flat, bruise (-) Aus : bowel sound (+) 4x/min Pal : Supel, tenderness (-), muscular defense (-) Per : tympani

Status localized
Regio parietal
L : vulnus laseratum 7x2x1cm,basic soft tissue,eneven edges,clear boundary, massive bleeding (-) F : tenderness (+), crepitation (-), M: (-)

Ample
Allergic :Medication : Past illness:Last meal : 4 hour before come to UGD RS UKI Event : fall from bycycle

Diagnosa
Mild head injury + vulnus laseratum regio parietalis sinistra

Treatment
Wound toilet Hecting regio parietalis sinistra mm/: - antibiotic
- dexoketrofen - Vit B complex

Mr. D (23)
M : Falling from a motorcycle I : extremity S : wound T:-

Primary survey
Airway : snoring -, gurgling -, stridor Clear Breathing :
Insp : bruise (-), chest wall movement symmetrical, RR 20 x/ min, hematoma (-) Pal : tenderness (-) Per : sonor right = left Aus : Basic breath sound vesicular rh-/- wh -/-

 C = warm extremities, Pulse = 90bpm, BP 110/70 mmHg, Temp = 36,3C, capillary refill time <2
Shock (-)

D = GCS E4M6V5, pupil isochors 3 mm/ 3 mm, centered, direct light reflex/indirect light reflex +/+ E = there is no life threatening wound

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 (-)

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 (-) Per : sonor right = left Aus : Basic breath sound vesicular

 Abdomen :
Ins : flat, bruise (-) Aus : bowel sound (+) 4x/min Pal : Supel, tenderness (-), muscular defense (-) Per : tympani

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

 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

Ample
Allergic :Medication : Past illness:Last meal : 3 hour before come to UGD RS UKI Event : fall from motorcycle

Diagnosa
Soft tissue injury regio interphalax pedis dextra digiti II-III + vulnus exoruation regio manus dextra

Treatment
Wound toilet Hecting regio interphalax pedis dextra digiti II-III Unhospitalized Mm/: antibiotic dextoketrofen vit c

Mrs S (85 YO)

Chief complain : - fall by her self

Additional complain : - pain of spine, and hip

History of illness :
Patient came to IGD RSU UKI with complaints fall 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 (-).

 Allergic : Medication : nifedipine Past illness : hipertention since 10 years ago, DM (+),hyperuresemia (+) Last meal : 4 hour before coming to hospital

Status Generalis
BP : 160/90mmhg Pulse : 98 bpm RR : 20 x/minutes Temp. : 36,3c GCS : E4M6V5

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 (-) Per : sonor right = left Aus : Basic breath sound vesicular

 Abdomen : Ins : flat, bruise (-) Aus : bowel sound (+) 4x/min Pal : Supel, tenderness (-), muscular defense (-) Per : tympani

Regio vertebrae
L: bruise (-), deformity (-) F: terderness lumbar area (+) , crepitation (-), M: left lateral flexi <45 Right lateral flexi< 45 left rotation <80 right rotation <80 flexion <50 extention < 60

 Ekstremitas :
Warm extremity Capp reffil <2 Motoric 5555 5555 5555 5555

Diagnosis
suspect fracture compretion vertebrae L4-L5

Treatment
unhospitalized Mm/ : analgesic calcium ranitidine