Professional Documents
Culture Documents
• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal :-
• Event : Train Accident
Working diagnose
• Non Medicamentosa :
– Pro hospitalized
– Below knee amputation dextra (CITO)
– Debridement hecting
• Medicamentosa :
– Ceftriaxone 1 amp
– Ondansetron 1 amp
– Ketesse drip 3 amp
– Plasminet 1 amp
– Vit. K 1 amp
2. Ms. L (17 Years Old)
MR. 56.41.05.00
Mechanism of the Trauma
Traffic accident
Injury of target organ
Maxilla dextra, sclera dextra, and superior lip
Symptoms and signs
Pain on maxilla dextra, headache, and nausea
Treatment Pre Hospital (Before UKI’S ER)
-
PRIMARY SURVEY
• Airway
– Look : no obstruction
– Listen : no extra breath sound (no gurgling, no snoring,
no stridor, no horseness)
– Feel : there were warm air from both nose and mouth
– Conclusion : CLEAR
• Breathing
– Inspection: bruise (-), chest wall movement symmetrical,
RR x/min, hematoma (–)
– Palpation : crepitation (-)
– Percussion: sonor right = left
– Auscultation: Basic breath sound vesicular, rh -/-, wh -/-
– Conclusion : CLEAR
• Circulation
– Warm extremities,
– Pulse = x/min
– BP = mmHg
– Temp= 36.5 0C
– RR = x/min
– CRT <2”
– Conclusion : No Sign Of Shock
• Disability
– GCS 14 (E4M6V5) pupil isochoric 3/3 mm, centered,
– Direct light reflex +/+ , indirect light reflex +/+
• Exposure
There was no life threatening wounds.
Secondary Survey
• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : rice and chicken at 7 am
• Event : Traffic Accident
Working diagnose
• Non Medicamentosa :
Reposition, hospitalized
• Medicamentosa :
– RL + Ikaneuron 1 amp, Ergotika 2 amp
– RL + Ketesse 3 amp
3. Mr. F (36 Years Old)
60.41.05.00
Mechanism of the Trauma
Acute of inflamatory
Injury of target organ
Under abdomen Right
Symptoms and signs
Pain on right abdomen
Treatment Pre Hospital (Before UKI’S ER)
-
PRIMARY SURVEY
• Airway
– Look : no obstruction
– Listen : no extra breath sound (no gurgling, no snoring,
no stridor, no horseness)
– Feel : there were warm air from both nose and mouth
– Conclusion : CLEAR
• Breathing
– Inspection: bruise (-), chest wall movement symmetrical,
RR x/min, hematoma (–)
– Palpation : crepitation (-)
– Percussion: sonor right = left
– Auscultation: Basic breath sound vesicular, rh -/-, wh -/-
– Conclusion : CLEAR
• Circulation
– Warm extremities,
– Pulse = 100x/min
– BP = 120/80mmHg
– Temp= 36.5 0C
– RR = 20x/min
– CRT <2”
– Conclusion : No Sign Of Shock
• Disability
– GCS 15 (E4M6V5) pupil isochoric 3/3 mm, centered,
– Direct light reflex +/+ , indirect light reflex +/+
• Exposure
There was no life threatening wounds.
Secondary Survey
• Allergy :-
• Medication :-
• Past Illness : fever
• Last Meal : porridge at 4 pm
• Event :-
Working diagnose
Acute appendicitis
TREATMENT
• Non Medicamentosa :
– Hospitalized
– Pro appendictomy (CITO)
– Diet
• Medicamentosa :
– Ceftriaxone 1x1gr
– RL 2 Kolf
– PCT 1amp (fever)
1. Mrs. S ( Years Old)
60.41.05.00
Mechanism of the Trauma
Traffic Accident
Injury of target organ
Pain in chest
Symptoms and signs
Pain in chest
Treatment Pre Hospital (Before UKI’S ER)
-
PRIMARY SURVEY
• Airway
– Look : no obstruction
– Listen : no extra breath sound (no gurgling, no snoring,
no stridor, no horseness)
– Feel : there were warm air from both nose and mouth
– Conclusion : CLEAR
• Breathing
– Inspection: bruise (-), chest wall movement symmetrical,
RR x/min, hematoma (–)
– Palpation : crepitation (-)
– Percussion: sonor right = left
– Auscultation: Basic breath sound vesicular, rh -/-, wh -/-
– Conclusion : CLEAR
• Circulation
– Warm extremities,
– Pulse = 100x/min
– BP = 120/70mmHg
– Temp= 36.6 0C
– RR = 20x/min
– CRT <2”
– Conclusion : No Sign Of Shock
• Disability
– GCS 15 (E4M6V5) pupil isochoric 3/3 mm, centered,
– Direct light reflex +/+ , indirect light reflex +/+
• Exposure
There was no life threatening wounds.
Secondary Survey
• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : rice and soup at 4 pm
• Event :-
Working diagnose
• Non Medicamentosa :
Oxygenation 3 Lpm
• Medicamentosa : -
5. Mr. P ( Years Old)
60.41.05.00
Mechanism of the Trauma
Accident
Injury of target organ
Pain in thumb of the right foot
Symptoms and signs
Swelling thumb
Treatment Pre Hospital (Before UKI’S ER)
Cleaned by antiseptic liquid
Secondary Survey
• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : fried chicken at 7 pm
• Event :-
Working diagnose
• Non Medication :
-
• Medication :
– Sporatic 2 x 100 mg tab
– Nonflamin 2 x 1 tab
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