Emergency Unit

Night Shift Report

March, 18th 2014
Assistant: Dr. Hendy Sibuea Co-assistant: Renol (chief) Debora Tiur Metiel Septa Tio Hizkia

1. Ms. S (36 Years Old)

09400500
Mechanism of the Trauma Unknown Injury of target organ Head Symptoms and signs Treatment Pre Hospital (Before UKIS ER)
Wound Toilet, Hecting, Oxygenization, IVFD; Ringer Lactate

PRIMARY SURVEY
Airway : CLEAR
Look Listen Feel : no obstruction : no extra breath sound (no gurgling, no snoring, no stridor, no horseness) : there were warm air from both nose and mouth

Breathing : CLEAR
Inspection: bruise (-), chest wall movement symmetrical, RR 20 x/min, hematoma () Pal : crepitation (-) Per : sonor right = left Aus : Basic breath sound bronchial, rh -/-, wh -/-

 Circulation : No Sign Of Shock

Warm extremities, Pulse = 100 x/menit Bp = 110/70 mmHg Temp= 36,50C CRT <2 mm,

Disability
GCS 15 (E4M6V5) pupil isochoric 3/3 centered, Direct light reflex/indirect light reflex +/+

Exposure
There was no life threatening wounds

Secondary Survey
Chief complaint
Additional Complaint

: Pain on bruises in Face and others : Pain on Abdominal

History of illness
Patient came accompanied with her family to UKIs ER reffered by TEBET HOSPITAL in case of Trauma. The history of trauma is unknown. Patient came to TEBET HOSPITAL at 2 pm and transfered to UKI HOSPITAL at 9 pm. The family also didnt know what happened to the patient. Patient came conscious but her jaw was broken she couldnt talk.

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 (-) 1. Vulnus excoriation on regio maksilofacia 2. Vulnus laceratum on regio frontalis regio nasal, and regio auris destra et sinistra (covered by bandage)

Thorax :
- Inspection : bruise (-), movement of chest wall symmetrical - Palpation : crepitation (-), palpation pain (-) - Percussion : sonor right = left, percussion pain (-) - Auscultation: Basic breath sound Vesicular right=left, wh-/-, rh-/-.

 Abdomen
- Inspection - Auscultation - Palpation
- Percussion

: flat, bruise (-), : bowel sound (+) 5x/min : tenderness (-), defense muscular (-) : tympani, percussion pain (+)

 In NGT bag, seen black fluid

 Superior Extremities
Warm, CRT <2, No Edema
Vulnus excoritaion on regio Ante brachii, regio meta Carpal sinistra

 Inferior Extremities
Look: edema (-), hematoma (-), rotation (-), Vulnus excoriation and vulnus laceratum on digiti 1,2 regio pedis dextra Feel: pain on palpation (+), crepitation (-) Move: active with no limitation

CT Brain: Bone Window

CT Brain : Fraktur Corpus Os Mandibula dextra + Proc. Zygomaticus

CT Brain : Brain Window

Laboratory Findings
Hb Leu Ery : 8.6 : 16.770 : 3.860.000

AMPLE
Allergy Medication Past Illness Last Meal Event :::: unknown : Traffict Accident

Working diagnose
Mild Head Injury + Suspect Intra Abdominal Bleeding + Anemia + Fractur Corpus Os Mandibula Dextra + protuberentia Mandibula Dextra + Proc. Zygomaticum + Vulnus Excoriation + Vulnus Laceratum

TREATMENT
Non Medicamentosa : Hospitalized Diet:
Calori needed 30cc/kgbb/hari Partial Parenteral Nutrition

Medicamentosa :
IVFD :
Futorolit 30mg/kgbb/hari (kristaloid + dextrose)

TREATMENT
Medica Mentosa
Omeprazole (ppi) tab 2x40mg Ketesse (analgetik) tab 3x35mg Vit K inj Meropenem inj 3x500mg

Transfusion Planning PRC 300 cc

Planning
Maintenance
Observation :
Conciousness, Vital Sign NGT until the fluid is clear

Nutrition :
Changing of nutrition uptake

Surgical Planning:
Orif Consul: Mouth Surgery