Emergency Unit

Night Shift Report

March, 23th 2014
Assistant:
Dr. Arhkipus/Dr. Lilis
Co-assistant:
Janter (chief)
Listia
Tri
Daniel
Sari
 1. Ms. R (19 Years Old)
MR. 3.40.05.
Mechanism of the Trauma
Traffic accident
Injury of target organ
Pedis dextra, tibia dextra, and superior lip
Symptoms and signs
Pain on pedis dextra, superior lip and massive
bleeding
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 20 x/min, hematoma (–)
– Palpation : crepitation (-)
– Percussion: sonor right = left
– Auscultation: Basic breath sound vesicular, rh -/-, wh -/-
– Conclusion : CLEAR
• Circulation
– Warm extremities,
– Pulse = 94 x/min
– BP = 120/80 mmHg
– Temp= 36.5 0C
– RR = 20 x/min
– CRT <2”
– Conclusion : No Sign Of Shock
• Disability
– GCS 14 (E4M6V4) pupil isochoric 3/3 mm, centered,
– Direct light reflex +/+ , indirect light reflex +/+
• Exposure
There was a life threatening wounds on regio pedis dextra
 Secondary Survey

• Chief complaint : pain on pedis dextra

• Additional Complaint: pain on tibia dextra
History of illness
A patient came accompanied with train
officer to UKI’s E.R because of an
accident in the train station at twenty
minutes ago. The patient didn’t know
how the accident happened. She felt
pain on the right foot and lips.
Projectile vomit (-), massive bleeding
(+) on regio pedis dextra, edema (-).
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA +/+ , right sclera
hematoma (+)
Ear : normal, LCS (-), bleeding (-),
blood spot (-)
Neck : Bruise (-), hematoma (-)

1. Vulnus laseratum on regio

labia superior (size : 1 x 0.3 cm)
2. Fraktur dental 21.22
• Superior Extremities
Look : Edema (-), hematoma (-), massive
bleeding (-) rotation (-)
Feel : Warm, CRT <2”, pain on palpation
(-), crepitation (-)
Movement : able to move gently
Motoric ++++/++++
Sensoric ++++/++++
• Inferior Extremities
Look: edema (-), hematoma (-), rotation (-)
Feel: pain on palpation (-), crepitation (-)
Movement : able to move gently
sensoric ++++/++++
motoric ++++/++++
CT-Brain
Photo cervical
Photo cruris pedis dextra
Laboratory
AMPLE

• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal :-
• Event : Train Accident
 Working diagnose

Mild head injury + Crush injury regio pedis

dextra + fracture 1/3 distal tibia et fibula
grade 3B + Fraktur dental 21.22+ vulnus
laseratum regio labia superior
 TREATMENT

• 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

• Chief complaint : pain on the maxilla dextra

• Additional Complaint: headache, nausea
History of illness
A patient came accompanied with train
officer to UKI’s E.R because of an
accident in the train station at twenty
minutes ago. She was fainted for few
minutes. The patient doesn’t know how
was the accident happening. She felt
pain on the right cheek, headache, and
nausea. Projectile vomit (-), massive
bleeding (-), edema (-).
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA +/+ , right sclera
hematoma (+)
Ear : normal, LCS (-), bleeding (-), blood spot (-)
Neck : Bruise (-), hematoma (-)

1. Vulnus excoriation on regio

maxillofacial (size : 7 x 4 cm),
superior (size : 0.8 x 0.3 cm)
2. Edema on the regio maxillofacial
• Superior Extremities
Look : Edema (-), hematoma (-), massive
bleeding (-) rotation (-)
Feel : Warm, CRT <2”, pain on palpation
(-), crepitation (-)
Movement : able to move gently
Motoric (++++)
Sensoric (++++)
• Inferior Extremities
Look: edema (-), hematoma (-), rotation (-)
Feel: pain on palpation (-), crepitation (-)
Movement : able to move gently
sensoric (++++)
motoric (++++)
X-ray schedel
X-ray cervical
AMPLE

• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : rice and chicken at 7 am
• Event : Traffic Accident
 Working diagnose

Mild Head Injury + Vulnus excoriation with

edema on maxillofacial + vulnus ulceration
on superior lip + right sclera hematoma
 TREATMENT

• 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

• Chief complaint : pain on under abdomen right

• Additional Complaint: fever
History of illness
A patient came accompanied with his
wife to UKI’s E.R because of pain in
under abdomen right at three days ago.
2 months ago, patient felt ill on upper
abdomen left to umbilicus, a few days
laters he had fever and it was cured
itself until Friday afternoon he got pain
and fever on under abomen right and
getting worse when he doing to do and
even cough. rojectile vomit (-), massive
bleeding (-), edema (-).
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA +/+ , right sclera
hematoma (+)
Ear : normal, LCS (-), bleeding (-), blood spot (-)
Neck : Bruise (-), hematoma (-)
 HEAD TO TOE
Abdomen :
inspection : flat, bruise
auscultation : bowel sound 10x/m
palpation : defense muscular
psoas sign (+), obturator sign (+)
percussion : tympani (+), pain (+)
• Superior Extremities
Look : Edema (-), hematoma (-), massive
bleeding (-) rotation (-)
Feel : Warm, CRT <2”, pain on palpation
(-), crepitation (-)
Movement : able to move gently
Motoric (++++)
Sensoric (++++)
• Inferior Extremities
Look: edema (-), hematoma (-), rotation (-)
Feel: pain on palpation (-), crepitation (-)
Movement : able to move gently
sensoric (++++)
motoric (++++)
X-ray Thorax
Laboratory
AMPLE

• 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

• Chief complaint : pain in chest

• Additional Complaint: headache
History of illness
A patient came accompanied with her
husband to UKI’s E.R complained headache
and pain on chest since 4 am. The patient
feels those after falling down from
motorcycle. She ride against the direction
then she without unknown cause the tire
slipped on the asphalt. The patient was
fainted for few minutes, then helped by
additional complained is wounds on both
knees. projectile vomit (-), massive bleeding
(-), edema (-).
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA +/+ , right sclera
hematoma (+)
Ear : normal, LCS (-), bleeding (-), blood spot (-)
Neck : Bruise (-), hematoma (-)
• Superior Extremities
Look : Edema (-), hematoma (-), massive
bleeding (-) rotation (-)
Feel : Warm, CRT <2”, pain on palpation
(-), crepitation (-)
Movement : able to move gently
Motoric (++++)
Sensoric (++++)
• Inferior Extremities
Look: edema (-), hematoma (-), rotation (-)
Feel: pain on palpation (-), crepitation (-)
Movement : able to move gently
sensoric (++++)
motoric (++++)
AMPLE

• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : rice and soup at 4 pm
• Event :-
 Working diagnose

Mild Head Injury + Vulnus Exccoration

regio Genues
 TREATMENT

• 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

• Chief complaint : pain in the thumb of the right

foot
• Additional Complaint: swelling thumb
History of illness
Patient came accompanied with his friend,
complained pain on the thumb of right foot
since the morning. The pain comes up after
he slipped fractions of the glass. It has been
cleaned by antiseptic liquid, but till
afternoon, the patient still felt the pain and its
swelling.
• Vital Sign
– Pulse = 88x/min
– BP = 160/100mmHg
– Temp= 370C
– RR = 20x/min
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA +/+ , right sclera
hematoma (+)
Ear : normal, LCS (-), bleeding (-), blood spot (-)
Neck : Bruise (-), hematoma (-)
• Superior Extremities
Look : Edema (-), hematoma (-), massive
bleeding (-) rotation (-)
Feel : Warm, CRT <2”, pain on palpation
(-), crepitation (-)
Movement : able to move gently
Motoric (++++)
Sensoric (++++)
• Inferior Extremities
Look: edema (-), hematoma (-), rotation (-)
Feel: pain on palpation (-), crepitation (-)
Movement : able to move gently
sensoric (++++)
motoric (++++)
AMPLE

• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : fried chicken at 7 pm
• Event :-
 Working diagnose

Vulnus Ulceration on the thumb of right foot

 TREATMENT

• Non Medication :
-
• Medication :
– Sporatic 2 x 100 mg tab
– Nonflamin 2 x 1 tab
THANK YOU 