NIGHT SHIFT

REPORT
2011
May, 30

1 patient trauma
 Mr. HH (24 YO )

Patient come to ER because get accident motorcycle

PRIMARY SURVEY
• Self protection (glove)
• Patient using collar neck
• Patient was brought by his family to ER
 ABCDE
• AIRWAY : Clear
• BREATHING :
• Inspection : symmetrical chest wall movement, bruise
(-), hematom (-)
• Auscultation : Basic breath sounds vesicular, wh -/-,
rh -/-
• Palpation : VF right = left, palpation pain (-),
crepitation (-)
• Percution : Sonor right = left, percussion pain (-)
 ABCDE

• CIRCULATION
Warm extremities, pulse 80 x/min, BP 130/100 mmhg,
temperature 36.5 C, cappilary refill < 2”
o

• DISABILLITY
GCS 15 E4V5M6, pupil isochoric 3 mm/3 mm, direct light reflex +/
+, indirect light reflex +/+
• EXPOSURE
There’s no life threatening injuries
 SECONDARY SURVEY

• Chief complaint : pain on his head

• Additional complaint : -
 ANAMNESIS

History of illness :
Alloamnesis
± 30 minute before patient arrive to ER , patient got motorcycle
accident. Patient use a full face helmed. After accident patient going
home and ask his family to take him to the hospital because he felt
pain in his head. On the way to hospital, his family smell alcohol from
his mouth. Patient is unconssiosness when arrived at hospital. Vomit
(-) patient cannot tell the story by him self
 AMPLE

• Allergy :-
• Medication :-
• Past Illness :-
• Last Meal : ± 2 hours before arrive to ER
• Event : motorcylce accident
 PHYSICAL EXAMINATION

HEAD TO TOE
General condition : look moderate illnes
Consciousness : GCS 15 E3V4M6
Blood Pressure : 130/100mmHg
Heart Rate : 80 times/minute
Respiration Rate : 24 times/minute
Temperature : 36,7°C
 PHYSICAL EXAMINATION

Eye : conjunctiva anemis -/-, sclera icteric -/-, pupil

isochoric 3mm/3mm,
direct light reflex +/+, indirect +/+
Neck : there’s no larged lymph
Thorax
• Insp : movement of chest wall is symmetrical, bruise (-)
• Pal : VF right = left, crepitation (-), pain on palpation (+)
• Per : sonor right = left, percussion pain (+)
• Aus : Basic breath sound vesicular, wh -/-, rh-/-
 PHYSICAL EXAMINATION

Abdomen
• Ins : flat, defence muscular (-)
• Pal : Tenderness (-), supel.
• Per : Tympani, percution pain (-)
• Aus : bowel sound (+) 4x/minutes

Extremity : warm extremities, cappillary refill < 2”, oedem -/-

Regio Zygoma:
L : hematome (+),
oedem (+)
F : temperature same as
arround, tenderness (+)
crepitation (-)
M : movement open and
close mouth (+)
Regio pedis dextra
L: vulnus excoriasis ; with size 3 x
1cm, 1 x 1 cm, hiperemis
F: tenderness (+)
M: movement active passive
unlimited.
CT- Brain
 DIAGNOSIS

Mild head injury + Fracture Os parietal sinistra +

Subarachnoid hematome regio falx cerebri +
intoxication alcohol
 TREATMENT

• Wound toilet
• Face mask 6 lpm
• Pro Hostpitalized → observation
• Mm/ Neurobion 2 x100 mg