Assessment of patients in the emergency room

Services in the emergency department are very important services to prevent death and
disability of victims. To be able to prevent the death and disability of the victim, you need your
cognitive, affective and psychomotor abilities to be able to help quickly and accurately.

Patients who enter the emergency room have a variety of diseases and our group took 1
case example along with the way the assessment had to be carried out.

Study and case examples in the emergency room

Assessment
1. Patient identity
Name : Mr. daniel
Age : 23 years
Gender : male
Address : church road elim
Person in charge
Name : Mr. Andi
Age : 63 years old
Gender : male
Relationship with patients : father

2.Medical history
1. Main complaint
Patients came to Kandou Hospital on June 22, 2020 with a motorcycle accident
the patient has decreased consciousness There is a hematoma on the head and
crepitations on the right thigh one-third medial dextra.
2. Current medical history
Patients come to the emergency room brought by his family at 20:30 a.m. on
June 22, 2020. Patients crash with motor vehicles with decreased consciousness
there is a hematoma on the head and crepitations on the right thigh one-third medial
dextra and hematoma face, bleeding from the mouth, ears and nose, the patient is
congested.

3.      Primary survey

a. Airway: there is an airway obstruction in the form of blood and mucus.
b. Breathing
Look: there is a chest wall development. 32 frequency / minute
Listen: the sound of breath in the hallway.
Feel: feels breath, looks at the muscles of breathing
c. Circulation: Cold acral, pale skin, bleeding in the ears, nose, mouth, CRT> 3 seconds, cold acral
d. Disability: GCS 7 (E2, M3, V2) and sopor awareness.

4. Secondary survey
Awareness : Sopor
General circumstances : Poor
GCS :7
Vital sign :
blood pressure : 100/60 mmhg
pulse : 102 X/m
breathing : 32 X/m
temperature : 37.8 c

5. Physical examination
a. Head
Inspection: symmetrical shape, dull-looking hair, hematoma on the face and head
Palpation: no lumps, tenderness in the occipital region.

b. Eye
Inspection: symmetrical shape, the client always closes his eyes because there are
hematoma eyes, blue eyes in both eyes.
Palpation: there is tenderness in both eyes.

c. Nose
Inspection: symmetrical shape, no polyps, bleeding from the nose
Palpation: there is tenderness.

d. Ear
Inspection: symmetrical shape, blood present
Palpation: there is tenderness

e. Mouth
Inspection: fresh blood, and mucus

f. Neck
Inspection: no enlargement of the thyroid gland, lymph and jugolar veins, cervical fracture
suspected.

g. Thorak
Inspection: symmetrical movement of the chest wall, there are muscles supporting
breathing, symmetrical chest shape
 Palpation: no tenderness, and no lumps
Percussion: resonant
Auscultation: stridor breath sounds, frequency 32 x / minute, no wheezing and ronhci

h. Heart
auscultation: there is a heartbeat with normal rhythm

i. Abdomen
Inspection: symmetrical shape, no injury
Auscultation: normal bowel bissing (10 x / min)
Palpation: elastic skin turgor, tenderness.

j. Genetalia
Inspection: Clean, no abnormalities

k. Skin
palpation : Elastic skin turgor
inspection : same skin color as other skin

l. Extremities
top : biceps and triceps reflex normal, no abnormalities, there is a scar on the right
hand, flexion and extension (+)
Bottom : no abnormalities, complete fingers,

6. Supporting Examination
a. Laboratory examination
No Check Type Normal Value
1 Hemoglobin 9.4
2. Hematocrit 33
3 Leukocytes 21,200
4 Platelets 198000
b. CT scan
There is cerebral edema in the head region

7. Therapeutic treatment
IVFD RL 30 tts / m
Dexa metahson 3x1, ampoule injection (iv)
Citicolin 3x1 ampoule, injection (iv)
Transamin acid 3x1 ampoules, injection (iv)
Vit k 3x1 ampoules, injection (iv)
Ketorolac 3x1 ampoule, injection (iv)
 Cefotaxime 2x1 gr, injection of ST (-) / IV
Polay catheter
NGT
Suction

Patients treated in the emergency room with therapy that has been determined until the patient's
condition is stable and then transferred to the treatment room