bismillah morpot 17 juni

Emergency Room

Morning Reportjune, 16th 2012

1 trauma and 2 non trauma

1. Mr. F (24 YO)

• Chief complaint : pain in his lower abdomen • Additional complaint :size of his scrotum was

bigger than usual

• History of illness : ( Autoanamnesis )

± 3 hours before admittance, patient suddenly felt pain in his lower abdominal , the pain is intermitten and felt like crushed, Patient also complained his scrotum got bigger than usual but can’t be repositioned into the right place. Nausea (+), vomitus (+) 1x, vomit of the last food eaten. Patient can defecate and gas normally. Patient had never been treated.Patient had the same problem since 2005, but bigger scrotum didn’t happen everyday. his scrotum got bigger while he’s doing a heavy job. But he can replaced the scrotum to the normal place by lift up his two legs or used his hands to reposition.

General ExaminationBP : 120/90mmHgHR : 60x/mRR : 16x/mT : 36.5°CHead : Bruise (-), hematom (-), tumor (-), blood (-)Eyes : Pupil round, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect Light Reflex+/+

Neck : Bruise (-), hematom (-), no nn.ll enlargement palpable

Thorax Insp : movement of chest wall symmetrical Pal : VF right=left Per : sonor right = left Aus : Basic breath sound vesicular, wh -/-, rh-/-

AbdomenIns : flat, hematom (-), bruise (-), defence

muscular (-)Pal : smooth, H/L not palpable enlargedPer : Percusion tenderness (-), TympaniAus : bowel sound (+) 2x/m

Extremitycap. refill < 2”, warm extremities, edema (-),

Localized status

• Regio scrotalis

insp: bigger scrotum , size 10x12 cm, transilumination (-), hematome (-)

pal : upper border unclear

Aus : bowel sound 1x/min

• Regio penis

Ins : Oue in the middle, circumsicion (+), pus (-), blood (-)

Pal : fibrosis (-), tenderness (-)

• Rectal toucherInsp : skin tag (-), mass (-)

Pal : TSA : squeezing

Mucose : smooth

Ampule recti no colapse

Tenderness (-)

Prostate

Upper pool palpable

Sulc medianus : palpable

Latero lateral : 2 cm

Nodul (-)

Handscoen :

Blood (-)

Feaces (-)

Thorax X-ray

DIAGNOSIS

Hernia scrotalis dextra stadium irreponible inkarserata

TREATMENT

• Pro herniotomy• Catheter initial urine : 100cc• NGT flowed• Diet : puasa• IVFD : II RL/24 jam• MM : terfacef 2x 1 g

Ranitidin 2 x 1 ampulOndancentron k/p muntah 1 ampKetesse 3 x 1 amp

PRIMARY SURVEY

Self protection (gloves)injury on her left leg due to scratch by the sharp

side of iron drum ,

Airway : Clear• Breathing :

Insp : RR: 30x/m, movement of chest wall symmetrical, bruise (-)

Pal : VF R=L Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer

An. N (5 years old)

• Circulation warm extremities, Pulse = 90 x/min , BP = 110/70 mmHg, Temp = 36,5°c, capillary

refill < 2”

• Disability GCS 15 – E4V5M6, pupil isochoric 3 mm / 3

mm, direct light reflex/indirect light reflex +/+, lateralization (-)

• Exposure There’s no life threatening wound

Secondary survey

Chief complain:

She has wound at her left leg

Secondary complain: -

History of illness (Anamnesis)

± 1 hours before admittance, Her parents told she was biking and arrived at home with wound in her left leg, she was scratched by the sharp side of the iron drum. According to the patient, she didn’t fall off the bike.

AMPLE

• Allergy : -• Medication : -• Past Illness : -• Last Meal : 3 hours before admittance• Event : scratch

Head : Bruise -, oedem -, Hematom -, tumor -, blood –Ear : normal, LCS -, blood –Neck : Bruise (-), hematom (-), no nn.ll enlargement

palpable Thorax :

Insp : movement of chest wall symmetrical, bruise (-) Pal : VF R=L Per : sonor right = left, Aus : Basic breath sound vesiculer, wh -/, rh-/-

Abdomen

Ins : flat, hematom (-), bruise (-), defence muscular (-)

Pal : tenderness (-)

Per : Percusion tenderness (-), Tympani

Aus : bowel sound + 4x/m

Ekstremitas

cap. refill < 2”, edema (-), warm extremity,

Localized Status

regio cruris sinistra

Look: vulnus scissum 5x1x1 cm

active bleeding (+), hematome (-)

Feel : tenderness(+), crepitation (-)

Move: active & passive movement normal

Diagnosis

Vulnus Scissum regio cruris sinistra

Therapy

• Wound toilet

• Hecting

• Vaccine TT

• Amoxicillin syrp 3 x II cth

• Paracetamol syrp 3 x II cth

1. Ms. I (14 YO)

• Chief complaint : swallowed a needle • Additional complaint : feel uncomfort in her

right upper abdominal

• History of illness : ( Autoanamnesis )

Half hour before came, patient told that she was swallowing a needle. At first she feel uncomfort in her throat. Then she feel uncomfort in her stomach , in her right upper abdominal ,because a needle for a few second. She was brought by her family.

Pain in abdominal (-) Dispnoe (-) Nausea (-), vomitus (-)

Patient didn’t take any action to reduce complaint.

General ExaminationBP : 110/70mmHgHR : 87x/mRR : 18x/mT : 36.5°CHead : Bruise (-), hematom (-), tumor (-), blood (-)Eyes : Pupil round, isochoric 3mm/3mm,

centered, Direct Light Reflex +/+, Indirect Light Reflex+/+

Orofaring : mucosa normal, edem (-), ulcer (-) , bleeding (-), corpus alienum (-),

Neck : swallow normal, Bruise (-), hematom (-), no nn.ll enlargement palpable

Thorax Insp : movement of chest wall symmetrical Pal : VF right=left Per : sonor right = left Aus : Basic breath sound vesicular, wh -/-, rh-/-

AbdomenIns : flat, hematom (-), bruise (-), defence

muscular (-)Pal : smooth, H/L not palpable enlargedPer : Percusion tenderness (-), TympaniAus : bowel sound (+) 8x/m

Extremitycap. refill < 2”, warm extremities, edema (-),

Diagnosa

• Corpus alienum suspect in gaster

Therapy

• Pro inpatient rejected

• MM:– sporetik 2x1 tab– Ketesse 3x1 tab– Omeprazole 1x1 tab

• Advice:– high fiber diet– Examine the stool – quick come to hospital when feel

nausea, pain in abdomen increase