Morpot 15 Des 2014

Night Shift Report
December 14th 2014
Asisstant:
Dr.Kezia / DR. AGUNG AJI / dr.Benny
Co.asisstant:
Samuel Keryanto (chief)
Pandu Haryo Jatmiko
Maria Linggar Pratiwi
Santi Masneno
Natasha Cinta Vinski
Wilona Devina
Tomi Eko Prasetyo
Trauma:
Hospitalize: 2
Non-Trauma: 1
Non-Hospitalize: 3
1. Mr. J (34 years old)

Mechanism of trauma : Injury organ : left kidney
Signs and symptoms : pain
Treatment pre hospital : -
PRIMARY SURVEY
Airway
Look
Listen
Feel
Breathing
Ins
Pal
Per
Aus
:
:
:
:
:
:
CLEAR
no obstruction
no extra breath sound
there were warm air from both nose and mouth
CLEAR
chest wall movement symmetrical, RR 21x/min,
bruise (-), hematoma ()
: vocal fremitus symmetrical
: sonor right = left
: basic breath sound vesicular, rh -/-, wh -/-
Circulation : No Sign Of Shock
Warm extremities, BP : 120/70

Pulse = 70 x/menit
RR : 16 x
Temp = 36,60C
CRT <2
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
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::: In the afternoon

:-
History of illness
Patient male 34 years old came to the ER
RSU UKI at 14.00 WIB with complain of pain
on suprapubic area since 1 week ago. The
pain spreads from his suprapubic area to the
left side of his back. He also has complaints
about the red colour of his urine which only
occurs once in a while, and most recently 3
days ago untill today, and pain on urination.
He did not seek help to a health proffesional
nor did he consume any medication to
reduce his complaints.
General status
-GCS 15, komposmentis

BP : 120/70
Pulse = 70 x/menit
RR : 16 x
Temp = 36,60C
HEAD TO TOE
Head
: Normocephaly
Eyes
: Pupil circular, isochoric
3mm/3mm, centered,
Direct Light Reflex
+/+, Indirect Light Reflex
+/+, CA -/Ear : Normal, Blood (-)
Neck : Bruise (-), Hematoma (-)
Thorax :
- Inspection : bruise (-), movement of chest

wall
symmetrical
- Palpation : Vocal fremitus symmetrical
- Percussion
: sonor right=left,
percussion pain (-)
- Auscultation
: basic breath sound
vesicular
right=left, wh-/-, rh-/-.
Abdomen :
-Inspection
-Auscultation
-Palpation
muscular
CVA -/+
-Percussion
(+)
: flat
: bowel sound (+) 4x/min
: tenderness (-), defense
(-), pain palpation (+),
: tympani, percussion pain
Extremity
CRT < 2
Sianosis
Edema
Warn extremity +/+
Laboratorium ( urinalisa)
Jenis pemeriksaan
hasil
Warna
Kuning keruh
1.030(urinalisa)
Laboratorium
Berat jenis
Ph
6.0
Blood
+2
Leukosit esterase
negatif
nitrit
negatif
Protein
+1
Bilirubin
negatif
Aseton
negatif
Reduksi
negatif
Uronilinogen
1.0
Leukosit
3-5
Eritrosit
1-3
Epitel
+1
Bakteri
positif
Silinder
negatif
Kristal
negatif
BNO 14.12.14
Working diagnose
Primary : Suspect nephrolitiasis

Secondary : Urinary tract infection
TREATMENT
Non-Medicamentosa:
Non Hospitalize
Diet : normal
Medicamentosa :
tofadex 2 x 1 tablet
ranitidin 2x1 tablet
Levofloxacin 2x1
Planning
Laboratorium :
BNO
2. Mr. A (30 years old)

Mechanism of trauma : injury caused by
motorcycle accident, the patient crashed
into the back of a car which made a sudden
stop, then he fell off his motorcycle and his
right side of the body hit the side of the
road, and hit his left leg on the car and
finally ending in a facing-downwards
position
Injury organ : right shoulder, left foot, left
and right hand
Signs and symptoms : pain, bruise on his
left knee, and bleeding in his lower lip.
PRIMARY SURVEY
Airway
Look
Listen
Feel
Breathing
Ins
Pal
Per
Aus
:
:
:
:
:
:
CLEAR
no obstruction
CLEAR
Circulation : No Sign Of Shock

Pulse = 88 x/menit
RR : 24 x
Temp = 37,10C
CRT <2
Disability
GCS 15 (E4M6V5)
Direct light reflex/indirect light reflex +/+
Exposure
There was no life threatening wounds
SECONDARY SURVEY
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::: In the evening

:-
History of illness
Patient male 30 years old came to the ER
RSU UKI at 18;30 WIB with complain of injury
due to a traffic accident about an hour ago
before he came to the hospital. Witness
stated that patent had lost conciousness for
15 seconds, but after that patient regained
conciousness by himself. Patien had injury in
lower lip, the 3rd 4th and 5th fingers on his
left hand, and his 4th, 5th finger on his right
hand, left knee. Nausea (-), Vomitting (-)
HEAD TO TOE
Head
: Normocephaly
Eyes
3mm/3mm, centered,
Direct Light Reflex
Thorax :

wall
symmetrical
- Percussion
: sonor right=left,
percussion pain (-)
- Auscultation
vesicular
Abdomen :
-Inspection
-Auscultation
-Palpation
muscular
-Percussion
(-)
: flat
(-), pain palpation (-)
Localis status
Lip
Lower lip : open wound
Hand :
Right hand : digiti 4th and 5th
Left hand : digiti 3rd , 4th , and 5th
Working diagnose
Vulnus Laceratum regio labia oris
TREATMENT
Non-Medicamentosa:
Non Hospitalize
Diet : normal
Medicamentosa :
- Neurobion 1 amp
-RL / 6 jam
Planning
Observation for 6 hours, doing a

physical examination on the patient
every hour
3. Ms. N (18 years old)

Mechanism of trauma : motorcycle injury,
she was riding motorbike without helmet
while her frineds was driving, and she felt
loss balance of the motorbike that she felt
hard causing her to have moderate head
injury and her conciousness
Injury organ : left klavikula, open wound on
her scalp
Treatment pre hospital : wound dressing
on the left hand, using ransel verband on
right shoulder
PRIMARY SURVEY
Airway
Look
Listen
Feel
Breathing
Ins
Pal
Per
Aus
:
:
:
:
:
:
CLEAR
no obstruction
CLEAR
Circulation :

Pulse = 60 x/menit
RR : 20 x
Temp = 36 0C
CRT <2
Disability
GCS 12 (E3V2M4)
Direct light reflex/indirect +/+ light reflex +/+
Exposure
There was an opened wound on the scalp of the patient
SECONDARY SURVEY
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::::-
History of illness
Patient female 18 years old came to the ER
of RSU UKI at 23.30 WIB after a traffic
accident with loss of conciousness, continous
bleeding from her ear and from an opened
wound on her head. She only opens her eyes
in response to pain (E2), Her best verbal
response is incomprehensable sounds (V2),
her best motorik respose is that she moves
towards localized pain as if blocking the pain
(M4).
HEAD TO TOE
Head
: Normocephaly
Eyes
3mm/3mm, centered,
Direct Light Reflex
Thorax :
Inspection : bruise (-), movement of chest

wall
symmetrical
Palpation : crepitation in clavicula sinistra ,
Vocal fremitus symmetrical
Percussion : sonor right=left, percussion
pain (-)
Auscultation
vesicular
Abdomen :
-Inspection
-Auscultation
-Palpation
muscular
CVA -/-Percussion
(-)
: flat
(-), pain palpation (-),
Laboratorium
Jenis pemeriksaan
hasil
Hb
11,1 g/dl
Ht
33,5 %
Thrombosit
284 rb/uL
Leukosite
27,400
KIMIA KLINIK
Gula darah sewaktu
151 mg/dL
CT Scan
Working diagnose
Primary : Irritative VP shunt tract
Secondary : contusio cerebri, edema cerebri, epidural
hematome
TREATMENT
Non-Medicamentosa:
Hospitalize
Diet : normal
Medicamentosa :
Ceftriaxone 2 x 1g
Ranitidin 2 x 1 tab
Planning
Laboratorium :
Darah Lengkap
CT Brain
Rontgen foto cervical
Observation every 15 minutes
4. Mr. Ad (50 years old)

Mechanism of trauma : The patient
uses VP shunt to
Injury organ : right shoulder, left foot,
and left hand
Treatment pre hospital : wound
dressing on the left hand, using ransel
verband on right shoulder
SECONDARY SURVEY
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::::-
History of illness
Patient arrives at the hospital complaining
about how from the right side of his head to
his neck a VP shunt tube is visible because it
is imprinted on his skin. It is also red and
swollen in the VP shunt imprint on the neck
since 1 week ago. The patient also complains
that he often feels headaches sometimes.
HEAD TO TOE
Head
: Normocephaly
Eyes
3mm/3mm, centered,
Direct Light Reflex
Neck
: Bruise (-), Hematoma (-), Swollen
(+ (in where the vp shunt is imprinted)
Thorax :

wall
symmetrical
- Percussion
: sonor right=left,
percussion pain (-)
- Auscultation
vesicular
Abdomen :
-Inspection
-Auscultation
-Palpation
muscular
CVA -/-Percussion
(-)
: flat
Working diagnose
Primary : Irritative VP shunt tract
Secondary : contusio cerebri, edema cerebri, epidural
hematome
TREATMENT
Non-Medicamentosa:
Hospitalize
Diet : normal
Medicamentosa :
Ceftriaxone 2 x 1g
Ranitidin 2 x 1 tab
Planning
Laboratorium :
Darah Lengkap
CT Brain
Observation every 15 minutes
5. Mr. S ( years old)

Mechanism of trauma : Injury organ : right scrotum
Treatment pre hospital-
PRIMARY SURVEY
Airway
Look
Listen
Feel
Breathing
Ins
Pal
Per
Aus
:
:
:
:
:
:
CLEAR
no obstruction
CLEAR
Circulation : no sign of shock

Pulse = 80 x/menit
RR : 20 x
Temp = 36 0C
CRT <2
Disability
GCS 15 (E4V5M6)
Exposure
SECONDARY SURVEY
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::::-
History of illness
Patient male 20 years old came to the ER of
RSU UKI at 23.30 WIB with complaint pain in
his scrotum. He feel like this since 3 hours
ago. Pain that he felt continously and
sometimes it makes him nausea until he got
vomitted. Right before he suffered from his
problem, he shouted aloud many times.
Patient had been before in years ago and he
got operated. He can urinate and defecated
normally
HEAD TO TOE
Head
: Normocephaly
Eyes
3mm/3mm, centered,
Direct Light Reflex
Thorax :

wall
symmetrical
- Percussion
: sonor right=left,
percussion pain (-)
- Auscultation
vesicular
Abdomen :
-Inspection
-Auscultation
-Palpation
muscular
CVA -/-Percussion
(-)
: flat
Genitalia
penis :
OUE : central, discharge-, fistel -
Scrotum :
Right scrotum : mass +, abnormally hard, pressure pain
+ , immobilized
Left scrotum : mass -, tenderness, pressure pain -,
mobilized
Working diagnose
Primary : Hernia Inguinalis

Secondary : -
TREATMENT
Non-Medicamentosa:
Hospitalize
Diet : normal
Medicamentosa :
kaltrofen supp
Planning
Laboratorium :
Darah Lengkap
USG
6. Mrs. (18 years old)

Mechanism of trauma : motorcycle
injury
Injury organ : right shoulder, left foot,
and left hand
Treatment pre hospital : wound
dressing on the left hand, using ransel
verband on right shoulder
PRIMARY SURVEY
Airway
Look
Listen
Feel
Breathing
Ins
Pal
Per
Aus
:
:
:
:
:
:
CLEAR
no obstruction
CLEAR
Warm extremities
Blood pressure : 120/80mmHg
Pulse = 88 x/menit
RR : 22 x
Temp = 36 0C
CRT <2
Disability
GCS 15 (E4V5M6)
Exposure
SECONDARY SURVEY
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::::-
History of illness
of RSU UKI at 23.30 WIB after a traffic
accident with loss of conciousness, continous
bleeding from her ear and from an opened
wound on her head. She only opens her eyes
in response to pain (E2), Her best verbal
response is incomprehensable sounds (V2),
her best motorik respose is that she moves
towards localized pain as if blocking the pain
(M4).
HEAD TO TOE
Head
: Normocephaly
Eyes
3mm/3mm, centered,
Direct Light Reflex
Thorax :

wall
symmetrical
- Percussion
: sonor right=left,
percussion pain (-)
- Auscultation
vesicular
Abdomen :
-Inspection
-Auscultation
-Palpation
muscular
CVA -/-Percussion
(-)
: flat
Laboratorium ( darah )
Jenis pemeriksaan
hasil
Hb
11,1 g/dl
Ht
33,5 (urinalisa)
%
Laboratorium
Thrombosit
284 rb/uL
Leukosite
27,400
KIMIA KLINIK
Gula darah sewaktu
151 mg/dL
Working diagnose
Primary : Moderate Head Injury

Secondary :
TREATMENT
Non-Medicamentosa:
Hospitalize
Diet : normal
Medicamentosa :
Ceftriaxone inj
Ranitidine inj
Ketorolac Inj
Manitol
Plasminex
Vit K Inj
Planning
Laboratorium :
Darah Lengkap
CT Brain
7. Ms. V (20 years)

Mechanism of trauma: motorcycle
injury
Injury organ : Signs and symptoms : pain
PRIMARY SURVEY
Airway
Look
Listen
Feel
Breathing
Ins
Pal
Per
Aus
:
:
:
:
:
:
CLEAR
no obstruction
CLEAR

Warm extremities
Blood pressure : 130/100mmHg
Pulse = 80 x/menit
RR : 20 x
Temp = 36 0C
CRT <2
Disability
GCS 15 (E4V5M6)
Direct light reflex/indirect +/+ light reflex +/
+
Exposure
There was no opened wound at the extremity
SECONDARY SURVEY
AMPLE
Allergy
Medication
Past Illness
Last Meal
Event
:::::-
History of illness
of RSU UKI. The patient was in a motorcycle
accident, since then he has been having
headaches and has been feeling spinny.
She was hysterical when she arrived at the
hospital because she was worried about her
friend who was also in the accident and in
critical condition. After 2 hours of observing
this patient, she is calm her vital signs are
back to normal (120/80, while on arrival her
blood pressure was 130/100)
HEAD TO TOE
Head
: Normocephaly
Eyes
3mm/3mm, centered,
Direct Light Reflex
Thorax :

wall
symmetrical
- Percussion
: sonor right=left,
percussion pain (-)
- Auscultation
vesicular
Abdomen :
-Inspection
-Auscultation
-Palpation
muscular
CVA -/-Percussion
(-)
: flat
Working diagnose
Primary : Multiple excoriation

Secondary :
TREATMENT
Non-Medicamentosa:
Observation TTV for 5 hour
Medicamentosa :
Ranitidine 2x1g
Tofedex 2x1g
Thank you

Morpot 15 Des 2014

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Morpot 15 Des 2014

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Night Shift Report

December 14th 2014

1. Mr. J (34 years old)

Circulation : No Sign Of Shock

Warm extremities, BP : 120/70

:::: In the afternoon

-GCS 15, komposmentis

- Inspection : bruise (-), movement of chest

Primary : Suspect nephrolitiasis

2. Mr. A (30 years old)

Circulation : No Sign Of Shock

Warm extremities, BP : 130/100

:::: In the evening

- Inspection : bruise (-), movement of chest

Observation for 6 hours, doing a

3. Ms. N (18 years old)

Warm extremities, BP : 140/90

Inspection : bruise (-), movement of chest

4. Mr. Ad (50 years old)

- Inspection : bruise (-), movement of chest

5. Mr. S ( years old)

Circulation : no sign of shock

Warm extremities, BP : 120/80

- Inspection : bruise (-), movement of chest

Primary : Hernia Inguinalis

6. Mrs. (18 years old)

Circulation : no sign of shock

- Inspection : bruise (-), movement of chest

Primary : Moderate Head Injury

7. Ms. V (20 years)

Circulation : no sign of shock

- Inspection : bruise (-), movement of chest

Primary : Multiple excoriation

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