Emergency Room

Night Shift Report

May, 20th 2010

1. Mr. A (41 YO)

PRIMARY SURVEY
Self protection
LSB
Neck collar
Spalex
Patient unconsciousness
Patient was driving a motorcycle and hit a motorcycle
Patient was taken by police

Physical Examination
Airway
: Snoring Guedel Clear
Breathing : RR : 33 x/min, Sat. o2 99%,
Face mask
10 lpm
Insp : movement of chest wall symmetrical,
bruise (-)
Pal
: VF cant be assessed, crepitation (-)
Per
: sonor right = left, percussion pain cant
be assessed
Aus
: Basic breath sound vesiculer, wh -/-, rh-/-

 C = warm extremities, Pulse = 74

x/min , BP
160/80 mmHg,Temp =
36,5 c, capillary refill <2
D = GCS E1V1M4, pupil isochoric 2 mm
/ 2 mm,
direct light reflex/indirect
light reflex +/+,
lateralization
(-)
E = Theres no life threatening wound

Secondary Survey
2. Ms I ( 11 YO)
Chief complaint
: unconsciousness
Additional complaint : -

SECONDARY SURVEY
History of illness :
30 minutes before admittance, police got
information from people around, their said patient was
driving a motorcycle in kampung melayu street, the
velocity is unknown, suddenly patient hit a motorcycle
in front of him then patient felt down.

with unconsiousness
condition. Police was taken patient to UKI hospital
Police

was

found

patient

Head impact, Chest impact and Abdominal impact

unknown, unconsciousness (+), vomit (-), nausea (-)

AMPLE
Allergy
: Medication
Past Illness
Last Meal : Event

::: Trafic Accident

HEAD TO TOE
General Examination
GC : Look severe illness
E1VxM4 Composmentis
BP : 140/80 mmHg
HR : 98 x/m
RR : 28 x/m
T : 36,5 C
Head
: Bruise +, Hematom -, edema +,
blood +
Eyes : Pupil round, isochoric 2mm/2mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+

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

enlarge
Thorax
Insp : movement of chest wall symmetrical,
bruise
(-)
Pal : VF cant be assessed, crepitation (-)
Per : sonor right = left, percussion pain cant
be
assessed
Aus : Basic breath sound vesiculer, wh -/-, rh-/Basic heart sound n, murmur -, gallop -

Abdomen
Ins : flat, hematom (-), bruise (-), defence
muscular (-)
Pal : smooth, H/L no palpable enlarged
Per : Percusion tenderness cant be
assessed,
Tympani
Aus : bowel sound + 3x/m
Ekstremitas
cap. refill < 2, edema (-), warm extremity
Right upper extremity deformity (+)
Spalex

Finger in every orifice

Nose
Ear
Mouth
Anus
OUE

: Blood (-), LCS (-)

: Blood (-), LCS (-)
: Blood (-)
: Blood (-)
: Blood (-)

Rectal toucher
TSA adequat
Ampula recti not collaps
Mucosa smooth
Tenderness pain cant be assessed
Prostat upper pool palpable, floating (-)
Med. Sulci concav, lateromedial 3 cm3cm
Hand scoen : blood (-), feses (+)

Localized Status
fronto dextra Region
L : excoriation wound 3x4 cm,
Bruise
(-), Edema (+), Hematom
(+),
active bleeding (-)
passive bleeding (+)
F : Tenderness cant assessed,
crepitation (-)

Localized Status
brachii dextra Region
L : Bruise (-), Edema (-),
Hematom
(-), Tumor (-), active bleeding
(-)
passive bleeding (-), deformity
(+)
F : Tenderness cant assessed,
crepitation (+)
M : active and passive movement
limited

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

CT BRAIN

THORAK XRAY

HUMERALE X ray

CERVICAL X RAY

CERVICAL X RAY

LABORATORIUM
HB
Leu
HT
Trom
GDS

14,4g/dl
11,3ribu/ul
41,9
%
237 ribu/ul
352 mg/dl

Laboratorium
Nilai
Ureum

16

Kreatinin

1.03

pH darah

7.387

pCO2

24.5

pO2

159.4

HCO3

14.8

Sat O2

99.4

BE

-7.5

TCO2

15.6

Kons O2

22.2

Na

144

3.8

Cl

104

DIAGNOSIS
Severe
head
injury
+
SubGaleal
Hematom
+
SubDural
hematom
temporoparietal
sinistra
region + Contusio cerebri +
closed Fr. Os humerus dextra
mid.1/3 segmented without
NVD dissorder

TREATMENT
Face mask 10 lpm
Neck collar, SLB, Spalex
Cateter foley, NGT, Intubation
FAST
IVFD : II RING AS
I RL
Manitol 150 cc ( 20 minutes )
Mm / : H2 blocker, Antibiotic, Antihemoragic,
Analgetic
Pro ICU