Download - Morport 26 Feb 2014
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Emergency Room
Morning ReportSeptember, 23th 2012
1 patient non trauma2 patients trauma
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1. Mrs. S ( 42 YO)
Chief complain
Pain on right lower abdominal
Additional complain
-
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History of present illness:
Patient came to the hospital complaining pain ather right lower stomach. She has that pain 3 hours
before admitted. The pain felt like stabbed,
continously, and getting worsen. The pain camefirst when she got menstruation day 1 and she
always got pain at lower left and right stomach
but never get worsen like this time. The patient
has never got any medicine or went to the doctor
before. Nausea (-), Vomitus (-), Anorexia (-),
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Defecation normal, the patient got her last
defecation 6 hours before admitted, pain when
defecation (-), abnormal feces (-).
Taking a pee normal, the patient still had a clear
urine and no pain.
She had ever got to doctor before and she was
diagnosed having cyst at her left ovarium. But
she never take any treatment after dignosed.
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Thorax :Insp : bruise (-), movement of chest wall
symmetrical
Pal : crepitation (-), palpation pain (-)
Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound vesiculer
right=left
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Abdomen :
Ins : flat, skin colour was the same.
Aus : bowel sound 5x/minute
Pal : pain on palpation (-), defence muscular (-)
Per : tympani, percussion pain (-)
Extremity :
Warm extremities, cap refill < 2”, edema (-).
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Diagnosis
Right Lower Abdomen Pain on Observation
Dd/ Ovarium Cyst
Chronic Appendicitis
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Treatment
• Non Medicamentosa
Patient went home
• Medicamentosa
Antibiotic
H2 Blocker
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2. Mrs. SA ( 65 YO)
Mechanism of the Trauma
Fell from the stairs
Injury of target organ
Vulnus excoriation at frontal lobe
Symptoms and signs
Pain
Transported by
Patient came with her family
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PRIMARY SURVEY
• Airway : No snoring, No gargling, No Stridor
Conclusion : CLEAR
• Breathing :
Insp : bruise -, chest wall movement symmetrical, RR
20 x/min, hematoma -
Pal : vocal fremitus simetrical right and left,
crepitation -
Per : sonor right = left
Aus : Basic breath sound bronchial, rh -/-, wh -/-
Conclusion : No pneumothorax, no hemothorax
CLEAR
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• Circulation
– warm extremities, Pulse = 80 bpm, Temp= 36,50C,
capillary refill <2” Conclusion : No sign of shock
• Disability – GCS 15 (E4M6V5) pupil isochoric 3/3 mm,
centered,
– direct light reflex/indirect light reflex +/+
• Exposure
There is no life threatening wounds
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AMPLE
• Allergy : -
• Medication : -
• Past Illness : -
• Last Meal : 3 hours before admittion
• Event : Fell from stairs
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Secondary Survey
• Chief complaint : wound at head after fell
from the stairs
• Additional complaint : -
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History of Illness
Patient came to the hospital after fell from the
stairs at her house 2 hours before admitted.
She got a wound at her head and she felt pain.
She was walking upstairs and fell at about 2
meters high. After fell the patient still could
walk. The pain felt not continously. Headache (-
), Vertigo (-), Nausea (+), Vomitus (+),Unconciussness (-)
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HEAD TO TOE
Head : Regio Frontalis dextra
L : open wound, dirty, basic skin, 3x1 cm ,bleeding (-)
F : crepitation (-)
Eyes : Pupil circular, isochoric 3mm/3mm,centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+
Ear : normal, LCS (-), blood (-)
Neck : Bruise (-), hematom (-)
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Thorax :Insp : bruise (-), movement of chest wall
symmetrical
Pal : crepitation (-), palpation pain (-) Per : sonor right = left, percussion pain (-)
Aus : Basic breath sound bronchial
right=left, wh-/-, rh-/-.
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Abdomen :
Ins : flat, bruise (-), muscular defense (-)
Aus : bowel sound (+) 5x/min
Pal : tenderness (-)
Per : tympani, percussion pain (-)
Extremity :
Warm extremities, cap refill < 2”, edema (-).
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Clinical foto
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Working diagnose
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TREATMENT
• Non Medicamentosa :
Hospitalized• Medicamentosa :
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3. Mr. HBP ( 50 YO)
Mechanism of the Trauma
wound at right hand because of a slice of mirror
Injury of target organ
Vulnus laceration of antebrachii dextra
Symptoms and signs
Pain
Transported by
Patient came with his wife
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PRIMARY SURVEY
• Airway : No snoring, No gargling, No Stridor
Conclusion : CLEAR
• Breathing :
Insp : bruise -, chest wall movement symmetrical, RR
16 x/min, hematoma -
Pal : vocal fremitus simetrical right and left,
crepitation -
Per : sonor right = left
Aus : Basic breath sound bronchial, rh -/-, wh -/-
Conclusion : No pneumothorax, no hemothorax
CLEAR
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• Circulation
– warm extremities, Pulse = 60 bpm, Temp= 36,90C,
capillary refill <2” Conclusion : No sign of shock
• Disability – GCS 15 (E4M6V5) pupil isochoric 3/3 mm,
centered,
– direct light reflex/indirect light reflex +/+
• Exposure
There is no life threatening wounds
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AMPLE
• Allergy : -
• Medication : -
• Past Illness : -
• Last Meal : 3 hours before admittion
• Event : Hand got a slice of mirror
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Secondary Survey
• Chief complaint : wound at right hand after
got a slice of mirror
• Additional complaint : -
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History of Illness
Patient came to the hospital after his right hand
got a slice of mirror 2 hours before admitted. He
was repairing the mirror when suddenly the
mirror fell and then his hand touched the mirroruntil got wound. He got a wound at her head and
he felt pain. After fell the patient still could
move his hand free. The pain felt notcontinously. Headache (-), Vertigo (-), Nausea
(+), Vomitus (+), Unconciussness (-)
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Abdomen :
Ins : flat, bruise (-), muscular defense (-)
Aus : bowel sound (+) 5x/min
Pal : tenderness (-)
Per : tympani, percussion pain (-)
Extremity :
Warm extremities, cap refill < 2”, edema (-).
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Clinical foto
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