Morpot Bedah 12 Nov 2014

Emergency Unit
Night Shift Report

November, 12th 2014
Assistant:
dr. Agung Aji / dr. Benny
Co-assistant:
Awardia Lydia (chief)
Riki
Ivana Las Maria
Innestyas Chrisanty
Francisca N. M. S
Natalia
Trauma: 4
Non Trauma: 2
Hospitalize: 4
Non Hospitalize: 2
4.Mr. AG ( 21 years old)

25.05.06.00
Mechanism of the Trauma
Patient hit another motorcycle from the contra
flow and was thud onto the asphalt. The anterior
of the body was hit the ground first. Patient was
thud around 1m from the crash spot.
Injury of target organ
Scalp and left nasolabialis
Symptoms and signs
Pain (+)
Treatment Pre Hospital (Before UKIS ER)
Sutured wound & verband on the right back side of the head
PRIMARY SURVEY
Airway : CLEAR
Look
Listen
Feel
: no obstruction
: no extra breath sound (gurgling (-), snoring (-),
stridor (-))
: there were warm air from both nose & mouth
Breathing : CLEAR
Inspection: bruise (-), chest wall movement
symmetrical, RR 22 x/min, hematoma ()
Pal
: crepitation (-)
Per
: sonor right = left
Aus
:vesicular basic breathe sound, rh -/-, wh -/-
Circulation : No Sign Of Shock
Warm extremities, blood pressure 100/80mmHg

Pulse = 82 x/menit
Temp = 360C
CRT <2
Disability
GCS 13 (E4M6V5) pupil isochoric 3/3 mm, centered,
Direct light reflex/indirect light reflex +/+
Exposure
There was no life threatening wounds
Secondary Survey
Chief Complain
Additional Complain
: headache
: vomit once, seizure once
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::: in the morning

: accident
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA -/Ear : normal, LCS (-), blood (-)
Neck : Bruise (-), hematoma (-)
Thorax :
- Inspection
: bruise (-), movement of chest wall

symmetrical
- Palpation : crepitation (-), palpation pain (-)
- Percussion : sonor right = left, percussion pain
(-)
- Auscultation: vesicular basic breathe sound
right=left, wh-/-, rh-/-.
Abdomen
- Inspection
- Auscultation
- Palpation
- Percussion
: flat, bruise (-),

: bowel sound (+) 9x/min
: tenderness (-),
muscular defense(-)
: tympani, percussion
pain (-)
Localized Status
SCALP
L : Vulnus laceratum, 2cm, suture (+), verband (+)
F : nyeri (+)
Nasolabialis Region
L : Vulnus laceratum 2cm
F : pain (+)
Ct scan
History of illness
Patient came to UKIs ER with headache after had
a motorcycle accident. He was on a fast velocity.
From the contra flow, there was another
motorcycle and the both crashed and patient was
thud onto the road 1m from the crash spot.
Vomit (+), seizure (+) 1x
Working diagnose
Mild Head Injury + Cerebral oedema +
Cerebral Contusion Frontalis and Occipitalis
Region + Epidural haematoma right parietal
region
TREATMENT
Non Medicamentosa :
- Hospitalized
- ICP & vital signs observation
- Head up 30+ O2 face mask 8 lpm
Medicamentosa :
IVFD : RL/24 hours + 3 amp Dexketoprofen
RL/24 hours + 1 amp Ikaneuron

Ceftriaxone 2 x 1mg
Ranitidine 2 x 1amp
Plasminex 3 x 1 amp
Vit. K 1 x 1 amp
Ergotica 2 x 1 tab
1. Mr. M ( 6 years old)

29.09.06.00
Fall in the bathroom
Supra Orbita Dextra
Symptoms and signs
Open wound
verban
PRIMARY SURVEY
Airway : CLEAR
Look
Listen
Feel
: no obstruction
: no extra breath sound (no gurgling, no snoring,
no stridor)
: there were warm air from both nose and mouth
Breathing : CLEAR
Pal
: crepitation (-)
Per
Aus
: Basic breath sound bronchial, rh -/-, wh -/-
Warm extremities,
Pulse = 96 x/menit
Temp = 360C
CRT <2
Disability
Exposure
Secondary Survey
Chief complaint
orbita dextra
Additional Complaint
: open wound on supra

:-
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::: in the evening

: accident
HEAD TO TOE
Head : Normocephaly
Thorax :
- Inspection

symmetrical
(-)
- Auscultation: Basic breath sound Vesicular
Abdomen
- Inspection
- Auscultation
- Palpation
- Percussion
: flat, bruise (-),

: tenderness (-), defense
muscular (-)
pain (-)
Localized Status
Regio supra orbita
dextra
Look: Vulnus Laceratum , 1
wounds ( 4 cm),wound basic
subcutis, edema (-), hematoma
(-), blood (+), active bleeding (), pus (-)
Feel: pain on palpation (+),
Movement: unlimited
History of illness
Patient came to UKIs ER in case of Trauma.
Patient have a pain on supra orbita dextra. 4 hours
before admitted to UKI, patient was falling in the
bathroom while he took a shower. Patient fell with
prone position. The patient still remembered the
event. Head injury denied, chest injury denied.
Dizziness (-), unconsciousness and vomitting was
denied.
Working diagnose
Vulnus Laseratum supra orbita dextra
TREATMENT
Non Medicamentosa :
- Non hospitalized
- Wound toilette
- Hecting
Medicamentosa :
Sporetik syr 2x1C
2. Mr. DB ( 9 years old)

26.09.06.00
Patient fall from the tree
Left head
Symptoms and signs
Open wound on the left head
-
PRIMARY SURVEY
Airway : CLEAR
Look
Listen
Feel
: no obstruction
: no extra breath sound (no gurgling, no snoring,
no stridor)
: there were warm air from both nose and mouth
Breathing : CLEAR
- Pal
: VF right = left
Per
: sonor right = left, , percussion pain
(+) on IC 5 and 6
Aus
: Basic breath sound vesiculer, rh -/-, wh -/-
Warm extremities,
Blood preasure : 110/70 mmHg
Pulse = 98 x/menit
Temp = 36,50C
CRT <2
Disability
GCS 15 (E4M6V5) pupil isochoric 3/3
centered,
Exposure
mm,
Secondary survey
HEAD TO TOE
Head : normocephali, open wound on the right
temporoparietal region
Neck : hematoma (-)
Thorax :
- Inspection

symmetrical
- Palpation : VF right = left
(-) Auscultation: Basic breath
sound Vesicular
Abdomen
- Inspection : flat, bruise (-),
- Auscultation: bowel sound (+) 9x/min
- Palpation : tenderness (-) on the upper
right abdomen, defense
muscular (-)
- Percussion : tympani, percussion
pain (-) on the upper right
abdomen
Extremities : warm, CRT < 2s, edem -/-
Secondary Survey
A
M
P
L
E
Allergic : Medication : Past Illness : Last meal : afternoon

Event : accident
Chief complaint
head
: open wound on the left
Additional Complaint
:-
History of illness
Patient came to RSU UKI ER with main
complaint open wound on the left part of
head. Patient was falling from tree when he
took a guava fruits. Patient fell with
position. The wound little bleeding. 1
hours ago. Dizziness and vomitting was
denied. Unconsciousness (-)
Localized status
Regio temporal sinistra
L : open wound on temporal
sinistra region 3cm,
bleeding (+) swelling (+)
F : pain (+), crepitation (-)
Ct scan
Working diagnose
- Mild head injury
- vulnus laceratum regio parietalis sinistra
-Oedema serebri
-Simple fracture (tabula os frontalis sinistra)
TREATMENT
Hospitalized
IVFD: RL/24 jam +manitol 60 cc
Head up 30
O2 2 Lpm
Konsul terapi bagian anak
Non Medicamentosa :
- wound toilet
- Hecting
Medicamentosa :
Ceftriaxone 2x1 gr (iv)
Ranitidin 2x 30 mg(iv)
Ketorolac (vial) tab 10 mg 3x1 tab
Brain Vit 1x1 cth
3. Mr. S ( 61 years old)

29.09.06.00
Patient fell onto the asphalt after a garbage truck
hit his porridge cart. His body hit the ground
first and the head after
Right side of the head and facial region
Symptoms and signs
Pain
None
PRIMARY SURVEY
Airway : CLEAR
Look
Listen
Feel
: no obstruction
: no extra breath sound (gurgling (-), snoring (-),
stridor (-))
: there were warm air from both nose & mouth
Breathing : CLEAR
Pal
: crepitation (-)
Per
Aus
: vesicular basic breathe sound, rh -/-, wh -/-
Warm extremities, blood pressure 180/100mmHg

Pulse = 70 x/menit
Temp = 360C
CRT <2
Disability
Exposure
Secondary Survey
Chief Complain
Additional Complain
: multiple wound
:-
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::: in the morning

: accident
HEAD TO TOE
Head : Normocephaly
Thorax :
- Inspection

symmetrical
(-)
- Auscultation: vesicular basic breathe sound
Abdomen
- Inspection
- Auscultation
- Palpation
- Percussion
: flat, bruise (-),

: tenderness (-), defense
muscular (-)
pain (-)
Localized Status
Regio Parietal Dextra
L : vulnus laceratum, 2,5cm, active bleeding (-),
subcutaneous wound base
F : pain (+)
Regio Frontalis
L : vulnus laceratum, 3cm, active bleeding (-),
subcutaneous wound base
F : pain (+)
Regio Zygoma Dextra
L : vulnus laceratum, 1cm, active bleeding (-),
cutaneous wound base
F : Pain (+)
History of illness
Patient came to UKIs ER with multiple wound on
the face and the head. He was standing beside his
porridge cart, from the back side of the cart, a
garbage truck suddenly hit the cart and patient got
dragged by the cart and fell to the back, onto the
asphalt. His body was the first hit the ground and
his head after. He was brought to the hospital right
away. Dizzyness (+), vomit twice.
Working diagnose
Mild Head Injury + Epidural Haematoma
Temporoparietal Right Region + Multiple
Vulnus Laceratum
TREATMENT
Non Medicamentosa :
- Hospitalized
- ICP and vital signs observation
- Head up 30+ O2 face mask 8 lpm
- Hecting
Medicamentosa :
IVFD : RL/24 hours + 3 amp Dexketoprofen
RL/24 hours + 2 amp Co-dergocrine Mesylate + 1 amp

Ikaneuron
Ceftriaxone 2 x 1mg
Ranitidine 2 x 1amp
Plasminex 3 x 1 amp
Vit. K 1 x 1 amp
Manitol 4 x 100 drip
5. Mr. M (47 Years Old)

23.14.04.00
Chief complain
Ulcer on right leg
Additional complain
Fever
History of present illness:

Patient came to the ER with the complaints of a
ulcer on leg since 7 days before admission.
Patient didnt know the reason of the ulcer. on the
beginning the ulcer is small and become bigger
day to day, especially on last 2 days. Patient feel
pain on the leg. Patient had give an oinment but it
didnt work. Fever (+) vomiting (-), dizzy (-),
headache (-)
General Examination
GC : Look mildly sick
Consciousness: E4M6V5 GCS 15 pupil
circular, isochoric 3mm/3mm, centered,
DLR +/+, ILR +/+,
Vital sign
BP : 130/90 mmHg
HR : 70 b/m
RR : 22 b/m
T
: 37,6C
Thorax :
Insp : movement of chest wall
symmetrical
Pal : vocal fremitus right = left
Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound vesiculer
right=left
Abdomen:
Inspection: looks flat

Ausculatation: bowel sounds 8x/m
Palpation: palpation pain (-)
Percussion: percussion pain (-) on the
lower abdomen
Extremities:
warm acral, crt < 2s
Localized status
Regio cruris dextra
L: ulcer on the cruris
dextra, 5 x 4 cm,
eritem, rough
surface, swelling
F: warm, pain +,
fluctuation +
Diagnosis
Abses cruris dextra posterior
Treatment
Non Medicamentosa
wound toilet
hospitalized
IVFD : 1 RL/24 hours
Medicamentosa
- Meropenem 2 x 200 mg
- Metronidazol drip 3 x 1
- Paracetamol 3 x 500 mg k/p
Ms. D (22 years old)

MR 43.02.06.00
Chief complain
: Pain of
the abdominal right lower quadrant.
Additional Complain
:-
History of Present Illness

Patient was brought by her mother to ER RSUKI
with complained of pain in the abdominal right lower
quadrant since three days ago. Patient felt pain centre
of the abdomen, to the left abdomen, to left lower
quadrant then to right lower quadrant of the
abdomen. Patient had came to clinic and doctor gave
the medicine but there wasnt progress of the
complain.
Since nine hours ago, the paint get worse. Vomit +.
Nausea +. Dizziness -.
GENERAL EXAMINATION
General Condition: moderately ill

GCS: E4M6V5
BP: 140/110 mmHg
Pulse Rate: 96x/minute
RR: 22x/minute
Temperature: 37
LOCALIZED STATUS
GENITAL AREA (Regio Iliaca
Dextra)
LOCALIZED STATUS
Regio Iliaca Dextra:
I : flat
P : tympani, percussion pain (-)
P : rebound pain (+) on
mcburney point
Working diagnose
Susp. Acute Appendicitis
TREATMENT
Hospitalized
IVFD : RL/ 24 hours
Mm/ Meropenem 2 x 200 mg ( IV )
Ranitidine 2 x 1 amp ( IV )
THANKYOU

Morpot Bedah 12 Nov 2014

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Emergency Unit

Night Shift Report

4.Mr. AG ( 21 years old)

Circulation : No Sign Of Shock

Warm extremities, blood pressure 100/80mmHg

:::: in the morning

: bruise (-), movement of chest wall

: flat, bruise (-),

RL/24 hours + 1 amp Ikaneuron

1. Mr. M ( 6 years old)

Circulation : No Sign Of Shock

: open wound on supra

:::: in the evening

: bruise (-), movement of chest wall

: flat, bruise (-),

2. Mr. DB ( 9 years old)

Circulation : No Sign Of Shock

: bruise (-), movement of chest wall

Extremities : warm, CRT < 2s, edem -/-

Allergic : Medication : Past Illness : Last meal : afternoon

: open wound on the left

3. Mr. S ( 61 years old)

Circulation : No Sign Of Shock

Warm extremities, blood pressure 180/100mmHg

:::: in the morning

: bruise (-), movement of chest wall

: flat, bruise (-),

RL/24 hours + 2 amp Co-dergocrine Mesylate + 1 amp

5. Mr. M (47 Years Old)

History of present illness:

Inspection: looks flat

Ms. D (22 years old)

History of Present Illness

General Condition: moderately ill

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