morpot 050513.pptx
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Emergency Room
Morning Shift ReportMay, 17th 2013
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1. Mr.J (63 YO)
M : Falling from a bycycle
I : head
S : wound
T : -
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Primary Survey
Airway : snoring -, gurgling -, stridor
Clear
Breathing :
Insp : bruise (-), chest wall movementsymmetrical, RR 20 x/ min, hematoma (-)
Pal : tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular
rh-/- wh -/-
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C = warm extremities, Pulse = 96bpm, BP
120/80 mmHg, Temp = 36,3C, capillary
refill time
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History of illness :Patients come to the RSU UKI due to a fall from a
bycycle 1 hour ago before coming to the hospital.
Patients bycycle hit by motorcycle from behind.
Patient fall and his head hit the asphalt. Patient
realized his head was cut and bleeding. Patient canrecall the events before and after accident. Head
impact (+), abdominal impact (-) vomiting (-), nausea (-
), unconsciousness (-), headache (+)
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HEAD TO TOE
Eyes : pupil isochors 3mm/3 mm, centered, direct light
reflex/ indirect light reflex +/+, hematoma (-/-)
Ear : Bruise (-), hematoma (-)
Neck : Bruise (-), hematoma (-)
Thorax :
Insp : bruise (-), movement of chest wall symmetrical
Pal : crepitation sub cutis (-), tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular
SECONDARY SURVEY
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Abdomen :
Ins : flat, bruise (-)
Aus : bowel sound (+) 4x/min
Pal : Supel, tenderness (-), musculardefense (-)
Per : tympani
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Status localized
Regio parietal
L : vulnus laseratum 7x2x1cm,basic soft
tissue,eneven edges,clear boundary,
massive bleeding (-)F : tenderness (+), crepitation (-),
M: (-)
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Ample
Allergic :-
Medication : -
Past illness:-
Last meal : 4 hour before come to
UGD RS UKI
Event : fall from bycycle
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Diagnosa
Mild head injury + vulnus laseratum
regio parietalis sinistra
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Treatment
Wound toilet
Hecting regio parietalis sinistra
mm/: - antibiotic- dexoketrofen
- Vit B complex
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Mr. D (23)
M : Falling from a motorcycle
I : extremity
S : wound
T : -
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Primary survey
Airway : snoring -, gurgling -, stridor
Clear
Breathing :
Insp : bruise (-), chest wall movementsymmetrical, RR 20 x/ min, hematoma (-)
Pal : tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular
rh-/- wh -/-
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C = warm extremities, Pulse = 90bpm, BP
110/70 mmHg, Temp = 36,3C, capillary
refill time
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History of illness
Patients come to the RSU UKI due to a fall from a
motorcycle 2 hour ago before coming to the hospital.
Patient riding a motorcycle at speeds 60km/hour, and he
use half face helmet.Patients motorcycle avoid some holes
and patient fall and his right body hit the pole. Patient can
recall the events before and after accident. Head impact (-
), abdominal impact (-) vomiting (-), nausea (-),
unconsciousness (-), headache (-)
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Secondary survey
HEAD TO TOE
Eyes : pupil isochors 3mm/3 mm,
centered, direct light reflex/ indirect light reflex
+/+, hematoma (-/-)
Ear : Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-)
Thorax :
Insp : bruise (-), movement of chest wall
symmetrical Pal : crepitation sub cutis (-), tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular
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Abdomen :
Ins : flat, bruise (-)
Aus : bowel sound (+) 4x/min
Pal : Supel, tenderness (-), musculardefense (-)
Per : tympani
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Status Localized
Regio manus sinistra digiti II
L: vulnus excoriation 2x2cm ,
edema (-)
F: crepitation (-), tenderness (+)
M : adduction
abduction
Regio tibialis anterior
dextra
L: vulnus excoriation 2x3 cm,
edema (-)
F: crepitation (-), tenderness
(+)
M : flexion
extention
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Regio interphalax pedis
dextra digiti II-III
L : vulnus scissum 4x5x2cm,
basic soft tissue, eneven
edges,clear boundary,
massive bleeding (-)
F : crepitation (-), terderness
(+)
M: adduction
abduction
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Ample
Allergic :-
Medication : -
Past illness:-
Last meal : 3 hour before come to UGDRS UKI
Event : fall from motorcycle
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Diagnosa
Soft tissue injury regio interphalax
pedis dextra digiti II-III + vulnus
exoruation regio manus dextra
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Treatment
Wound toilet
Hecting regio interphalax pedis
dextra digiti II-III
Unhospitalized
Mm/: antibiotic
dextoketrofenvit c
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Mrs S (85 YO)
Chief complain :
- fall by her self
Additional complain :
- pain of spine, and hip
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History of illness :
Patient came to IGD RSU UKI with complaintsfall by her self in sit position. Patient felt pain at
her spine and her hip. Patient walk with help
from cane. Patient also complaint heartburn and
nausea. Patient has hipertention history (+), DM(+), hyperuresemia (+).urinating disorder (-)
Defecate disorder (-).
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Allergic : -
Medication : nifedipine
Past illness : hipertention since 10
years ago, DM (+),hyperuresemia (+)
Last meal : 4 hour before coming to
hospital
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Status Generalis
BP : 160/90mmhg
Pulse : 98 bpm
RR : 20 x/minutes
Temp. : 36,3c
GCS : E4M6V5
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Secondary survey
HEAD TO TOE Eyes : pupil isochors 3mm/3 mm, centered, direct light
reflex/ indirect light reflex +/+, hematoma (-/-), conjuctiva
anemis (+/+)
Ear : Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-)
Thorax :
Insp : bruise (-), movement of chest wall symmetrical
Pal : crepitation sub cutis (-), tenderness (-)
Per : sonor right = left
Aus : Basic breath sound vesicular
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Abdomen :
Ins : flat, bruise (-)
Aus : bowel sound (+) 4x/min
Pal : Supel, tenderness (-), muscular defense
(-)
Per : tympani
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Regio vertebrae
L: bruise (-), deformity (-)
F: terderness lumbar area (+) , crepitation (-),
M: left lateral flexi
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Ekstremitas :
Warm extremity
Capp reffil
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Diagnosis
suspect fracture compretion vertebrae
L4-L5
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Treatment
unhospitalized
Mm/ : analgesic
calcium
ranitidine
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