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Emergency Room

Morning Shift Report


June 19th 2013

Ms. T ( 25 YO)
M : the left toe crushed by car I : regio pedis sinistra digiti I S : pain T : motorcycle

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

C = warm extremities, Pulse = 100 bpm, BP 130/90 mmHg, capillary refill time <2

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

History of illness :
Patient came to RSU UKI with the chief complain pain 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 toe was pinned down under the car tires for about 1 minute. Patient was taken to RS UKI immediately.

SECONDARY SURVEY
HEAD TO TOE
Eyes

: pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+ Ear : Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-) Thorax :

Insp Pal Per Aus

: bruise (-), movement of chest wall symmetrical : crepitation (-), tenderness (-) : sonor right = left : Basic breath sound vesicular right = left

Abdomen :

: flat, bruise (-) Aus : bowel sound (+) 6x/min Pal : Supel, tenderness (-), muscular defense (-) Per : tympani Extremity: Warm extremities, cap. refill time < 2, edema (-)

Ins

Localized Status
Regio Pedis Sinistra Digiti I

Look : vulnus excoriation 2x1cm, active bleeding (-), cyanosis (+), the nail almost loose Feel : tenderness (+), edema (-) Move : active (+) passive (+)

Diagnosis
Closed fracture phalang distal digiti I pedis

sinistra nondisplaced

TREATMENT
Wound toilet
Extraction of the nail Antibiotic

Analgetic
Antagonist H2 receptor

Ms. M (51YO)
Chief complain: lower right abdomen pain

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. Patient already menopause.

General Status
General Condition : Mild Illness Appearance GCS : E4V5M6 BP : 110/70 mmHg Pulse : 68 bpm Temp : 36,30 C RR : 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 (-) Per : sonor right = left Aus : Basic breath sound vesicular right = left

Abdomen :
Ins Aus Pal Per Extremity: Warm extremities, cap. refill time < 2, edema (-)

: flat, bruise (-) : bowel sound (+) 8x/min : Supel, tenderness (+), muscular defense (-) : tympani

Diagnosis
Post appendectomy e.c appendicitis chronic Lower right abdomen pain e.c susp. UTI

Treatment
Analgetic
Vitamin B12 Antagonist H2 receptor