morport 09maret 2014
Transcript of morport 09maret 2014
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Emergency Room
Morning ReportMarch, 9th 2014
3 patient trauma
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1. Mrs. R ( 57 YO)
Mechanism of the Trauma
Fell from the motorcycle
Injury of target organ
laserated wound at supraorbital region dextra
Symptoms and signs
-
Treatment by: -
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PRIMARY SURVEY
•
Airway : No snoring, No gargling, No StridorConclusion : CLEAR
• Breathing :
Insp : bruise -, chest wall movement symmetrical, RR
20 x/min, hematoma -Pal : vocal fremitus simetrical right and left,
crepitation -
Per : sonor right = left
Aus : Basic breath sound bronchial, rh -/-, wh -/-
Conclusion : No pneumothorax, no hemothorax
CLEAR
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• Circulation
– warm extremities, Pulse = 80 bpm, Temp=
36,50C, capillary refill <2” Conclusion : No sign of shock
• Disability – GCS 15 (E4M6V5) pupil isochoric 3/3 mm,
centered,
– direct light reflex/indirect light reflex +/+
• Exposure
There is no life threatening wounds
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AMPLE
• Allergy : -
• Medication : -
• Past Illness : -
• Last Meal : 15 minutes before
admittion
• Event : Fell from stairs
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Secondary Survey
• Chief complaint : wound at head after fell
motorcycle accident
• Additional complaint : -
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History of Illness
• Patient came with complaint wound on forehead
region. History of motorcycle accident. Faint
denied, vomits denied. Seizure denied. Patient
also complaint that she had pain on that wound.
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General Examination
GC : Look moderately sick
Consciousness: E4M6V5 GCS 15 pupil
circular, isochoric 3mm/3mm, centered,
DLR +/+, ILR +/+,Vital sign
BP : 120/80 mmHg
HR : 82 b/m
RR : 20 b/m
T : 36,5°C
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Localised status
Head to toe :
L : Vulnus Laseratum regio supraorbita
dextra , dasar soft tissue size 3 x 1 x 0,5
cmF : Pain (-)
M : -
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Thorax :Insp : bruise (-), movement of chest wall
symmetrical
Pal : crepitation (-), palpation pain (-) Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound vesiculer
right=left
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Abdomen :
Ins : flat, skin colour was the same.
Aus : bowel sound 5x/minute
Pal : pain on palpation (-), defence muscular (-)
Per : tympani, percussion pain (-)
Extremity :
Warm extremities, cap refill < 2”, edema (-).
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Diagnosis
Vulnus laseratum regio supra orbita
dextra
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Treatment
•
Non MedicamentosaWound Toilet
Hecting
ATSOutpatient
• Medicamentosa
Cefixime 2 x 100 mg
Ketesse 3 x 1 tab
Ranitidine 2 x 1 tab+
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2. Mr. R ( 35 YO)
Mechanism of the Trauma
Fell from the motorcycle
Injury of target organ
Vulnus excoriation at right foot and left foot
Symptoms and signs
-
Transported by
Patient came with her family
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PRIMARY SURVEY
• Airway : No snoring, No gargling, No Stridor
Conclusion : CLEAR
• Breathing :
Insp : bruise -, chest wall movement symmetrical, RR
20 x/min, hematoma -
Pal : vocal fremitus simetrical right and left,
crepitation -
Per : sonor right = left
Aus : Basic breath sound bronchial, rh -/-, wh -/-
Conclusion : No pneumothorax, no hemothorax
CLEAR
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• Circulation
– warm extremities, Pulse = 80 bpm, Temp= 36,50C,
capillary refill <2” Conclusion : No sign of shock
• Disability – GCS 15 (E4M6V5) pupil isochoric 3/3 mm,
centered,
– direct light reflex/indirect light reflex +/+
• Exposure
There is no life threatening wounds
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AMPLE
• Allergy : -
• Medication : -
• Past Illness : -
• Last Meal : 15 minutes before
admittion
• Event : Fell from motorcycle
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Secondary Survey
• Chief complaint : wound at right foot and
left foot after fell from motorcycle
• Additional complaint : -
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History of Illness
• Patient came with complaint wound at right
foot and left foot. History of motorcycle
accident. Faint denied, vomits denied. Seizure
denied. Patient also complaint that he had painon that wound.
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HEAD TO TOE
Head : Regio pedis dextra et sinistra
L :Vulnus excoriatum regio pedis dextra et
sinistra
F : Pain (-)M : -
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Thorax :Insp : bruise (-), movement of chest wall
symmetrical
Pal : crepitation (-), palpation pain (-) Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound bronchial
right=left, wh-/-, rh-/-.
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Abdomen :
Ins : flat, bruise (-), muscular defense (-)
Aus : bowel sound (+) 5x/min
Pal : tenderness (-)
Per : tympani, percussion pain (-)
Extremity :
Warm extremities, cap refill < 2”, edema (-).
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Clinical foto
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Working diagnose
Vulnus excoriatum regio pedis dextra et
sinistra
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TREATMENT
• Non Medicamentosa :
Outpatient• Medicamentosa :
Ketesse 3 x 1 tab
Ranitidine 2 x 1 tab
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3. Mr. H ( 43 YO)
Mechanism of the Trauma
wound at right hand and left hand
Injury of target organ
Vulnus excoriasi multiple regio manus dextra etsinistra
Symptoms and signs
-Transported by
Patient came with his friend
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PRIMARY SURVEY
• Airway : No snoring, No gargling, No Stridor
Conclusion : CLEAR
• Breathing :
Insp : bruise -, chest wall movement symmetrical, RR
16 x/min, hematoma -
Pal : vocal fremitus simetrical right and left,
crepitation -
Per : sonor right = left
Aus : Basic breath sound bronchial, rh -/-, wh -/-
Conclusion : No pneumothorax, no hemothorax
CLEAR
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• Circulation
– warm extremities, Pulse = 82 bpm, Temp= 36,50C,
capillary refill <2” Conclusion : No sign of shock
• Disability – GCS 15 (E4M6V5) pupil isochoric 3/3 mm,
centered,
– direct light reflex/indirect light reflex +/+
• Exposure
There is no life threatening wounds
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AMPLE
• Allergy : -
• Medication : -
• Past Illness : -
• Last Meal : 3 hours before admittion
• Event : -
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Secondary Survey
• Chief complaint : wound at right hand and
left hand
• Additional complaint : -
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History of Illness
Patient came to the hospital with complaint
wound at right hand and left hand. History of
trauma glass ± 2 hours before admission. Active
bleeding (-), numb (-), Active arm movement inall directions.
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HEAD TO TOE
Head : Normocephali
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+
Ear : normal, LCS (-), blood (-)
Neck : Bruise (-), hematom (-)
Thorax :
Insp : bruise (-), movement of chest wall
symmetrical
Pal : crepitation (-), palpation pain (-)
Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound bronchial right=left, wh-/-, rh-/-.
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Abdomen :
Ins : flat, bruise (-), muscular defense (-)
Aus : bowel sound (+) 5x/min
Pal : tenderness (-)
Per : tympani, percussion pain (-)
Extremity :
Warm extremities, cap refill < 2”, edema (-).
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Clinical foto
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Working diagnose
Vulnus Excoriatum multiple regio manus
dextra et sinistra