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Emergency Room

Morning Report

September, 23 th 2012

1 patient non trauma

2 patients trauma

1. Mrs. S ( 42 YO)

Chief complain

Pain on right lower abdominal

Additional complain

-

History of present illness:

Patient came to the hospital complaining pain at

her right lower stomach. She has that pain 3 hours

before admitted. The pain felt like stabbed, continously, and getting worsen. The pain came

first when she got menstruation day 1 and she

always got pain at lower left and right stomach but never get worsen like this time. The patient

has never got any medicine or went to the doctor

before. Nausea (-), Vomitus (-), Anorexia (-),

Defecation normal, the patient got her last

defecation 6 hours before admitted, pain when

defecation (-), abnormal feces (-).

Taking a pee normal, the patient still had a clear urine and no pain.

She had ever got to doctor before and she was

diagnosed having cyst at her left ovarium. But

she never take any treatment after dignosed.

General Examination

GC : Look moderately sick Consciousness: E4M6V5 GCS 15 pupil circular, isochoric 3mm/3mm, centered, DLR +/+, ILR +/+,

Vital sign

BP

: 110/80 mmHg

HR

:

82 b/m

RR

:

18 b/m

T

: 37,3°C

Thorax :

Insp : bruise (-), movement of chest wall symmetrical

  • Pal : crepitation (-), palpation pain (-)

  • Per : sonor right = left, percussion pain (-)

Aus

:

right=left

Basic

breath

sound

vesiculer

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 (-).

Diagnosis

Right Lower Abdomen Pain on Observation

Dd/ Ovarium Cyst

Chronic Appendicitis

Treatment

Non Medicamentosa Patient went home

Medicamentosa Antibiotic H2 Blocker

2. Mrs. SA ( 65 YO)

Mechanism of the Trauma

Fell from the stairs

Injury of target organ

Vulnus excoriation at frontal lobe

Symptoms and signs

Pain

Transported by

Patient came with her family

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

crepitation -

fremitus

simetrical

right

and

  • : sonor right = left

Per

  • : Basic breath sound bronchial, rh -/-, wh -/-

Aus

left,

Conclusion : No pneumothorax, no hemothorax

CLEAR

Circulation

warm extremities, Pulse = 80 bpm, Temp= 36,5 0 C, capillary refill <2

Conclusion : No sign of shock

Disability

GCS

15

(E4M6V5)

pupil

isochoric

3/3

centered, direct light reflex/indirect light reflex

+/+

mm,

Exposure

There is no life threatening wounds

AMPLE

Allergy

: -

Medication

: -

Past Illness

: -

Last Meal

: 3 hours before admittion

Event

: Fell from stairs

Secondary Survey

Chief complaint

Additional complaint

: wound at head after fell

:

from the stairs -

History of Illness

Patient came to the hospital after fell from the

stairs at her house 2 hours before admitted.

She got a wound at her head and she felt pain. She was walking upstairs and fell at about 2 meters high. After fell the patient still could walk. The pain felt not continously. Headache (- ), Vertigo (-), Nausea (+), Vomitus (+), Unconciussness (-)

HEAD TO TOE

Head : Regio Frontalis dextra

L : open wound, dirty, basic skin, 3x1 cm ,

bleeding (-)

F : crepitation (-)

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

right=left, wh-/-, rh-/-.

bronchial

Abdomen :

Ins

: flat, bruise (-), muscular defense (-)

Aus

: bowel sound (+) 5x/min

Pal

: tenderness (-)

Per

: tympani, percussion pain (-)

Extremity :

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

Clinical foto

Working diagnose

TREATMENT

Non Medicamentosa :

Hospitalized Medicamentosa :

3. Mr. HBP ( 50 YO)

Mechanism of the Trauma

wound at right hand because of a slice of mirror

Injury of target organ

Vulnus laceration of antebrachii dextra

Symptoms and signs

Pain

Transported by

Patient came with his wife

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

crepitation -

fremitus

simetrical

right

and

  • : sonor right = left

Per

  • : Basic breath sound bronchial, rh -/-, wh -/-

Aus

left,

Conclusion : No pneumothorax, no hemothorax

CLEAR

Circulation

warm extremities, Pulse = 60 bpm, Temp= 36,9 0 C, capillary refill <2

Conclusion : No sign of shock

Disability

GCS

15

(E4M6V5)

pupil

isochoric

3/3

centered, direct light reflex/indirect light reflex

+/+

mm,

Exposure

There is no life threatening wounds

AMPLE

Allergy

: -

Medication

: -

Past Illness

: -

Last Meal

: 3 hours before admittion

Event

: Hand got a slice of mirror

Secondary Survey

Chief complaint got a slice of mirror

Additional complaint

: wound at right hand after

:

-

History of Illness

Patient came to the hospital after his right hand

got a slice of mirror 2 hours before admitted. He

was repairing the mirror when suddenly the mirror fell and then his hand touched the mirror

until got wound. He got a wound at her head and

he felt pain. After fell the patient still could move his hand free. The pain felt not

continously. Headache (-), Vertigo (-), Nausea

(+), Vomitus (+), Unconciussness (-)

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-/-.

Abdomen :

Ins

: flat, bruise (-), muscular defense (-)

Aus

: bowel sound (+) 5x/min

Pal

: tenderness (-)

Per

: tympani, percussion pain (-)

Extremity :

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

Clinical foto

Working diagnose

Vulnus Laceratum regio Antebrachii Dextra

DM type II uncontrolled

TREATMENT

Non Medicamentosa :

Patient went home

Necrotomie + Debridement + Primary

Hecting

Medicamentosa :

Antibiotic

H2 blocker