View
231
Download
0
Category
Preview:
Citation preview
8/10/2019 MORPOT 17.12.14
1/43
Emergency Unit
Night Shift ReportDecember 16th2014
Assistant: dr. Hendy/dr. Benny
Co-assistant:
Dian Nur Martika A
Glen Jacobs S
Leonard Evan M
Kharisma Pertiwi
Riya Hanaza RNadia Latifa D
Dyah Anjani K.S
8/10/2019 MORPOT 17.12.14
2/43
Trauma: 1
Non-Trauma: 2
Hospitalize: 3
Non-Hospitalize: -
8/10/2019 MORPOT 17.12.14
3/43
1. Ms. W (73 years old)
Main complaint : bleeding from
mammae dextra
Secondary complaint : -
Pre hospital treatment : tampon on
dextra mammae, analgetic, vit K
8/10/2019 MORPOT 17.12.14
4/43
History of illness
Patient came to ERS RSU UKI with main complaint
bleeding from mammae dextra 3 days ago. Bleeding a
lot continously. In Sept 2014 patient went to
RS.Dharmais to consultation about mass in breast.
Diagnose from RS. Darmais was mammae cancer butshe and her family denied to get chemotherapy. She has
been got some medication like analgetic, vit K, and
tampon on dextra mammae.
8/10/2019 MORPOT 17.12.14
5/43
Vital Sign
General conditions : look severe sick
consciousness: GCS E3 V2 M5
BP : 110/70mmHg Pulse: 84x/menit
RR: 22 x/menit
temperature : 36,4 oC
8/10/2019 MORPOT 17.12.14
6/43
HEAD TO TOE
Head: Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm, centered,
Direct Light Reflex +/+, Indirect Light Reflex
+/+, CA -/-
Ear : Normal, LCS (-), Blood (-)
Neck : Bruise (-), Hematoma (-)
8/10/2019 MORPOT 17.12.14
7/43
Thorax :- Inspection : bruise (-), movement of chest wall
symmetrical
- Palpation : -
- Percussion : -
- Auscultation : basic breath sound vesicular
left, wh-/-, rh-/-.
8/10/2019 MORPOT 17.12.14
8/43
Abdomen :
- Inspection : flat, bulging (-)
- Auscultation : bowel sound (+) 8x/min
-Palpation : tenderness (-), defense muscular
(-), pain palpitation (-)
- Percussion : tympani, percussion pain (-)
8/10/2019 MORPOT 17.12.14
9/43
Extremities
CRT
8/10/2019 MORPOT 17.12.14
10/43
Locale status
mammae :
I :mass diameter : 13cm Thick : 5 cm,
ulcus +, pus +, active bleeding
Pal : -
Per : -
A: basic breath sound vesicularleft, wh-/-, rh-/-.
8/10/2019 MORPOT 17.12.14
11/43
8/10/2019 MORPOT 17.12.14
12/43
Laboratorium 16/12/14
8/10/2019 MORPOT 17.12.14
13/43
8/10/2019 MORPOT 17.12.14
14/43
Working diagnose
Ca Mammae dextra T4bNXM1
Anemia
Hiponatremia
Hipoklorinemia
hipoalbuminemia
8/10/2019 MORPOT 17.12.14
15/43
TREATMENT
Non-Medicamentosa:Hospitalize
Diet : high protein high karbohidrat
NGT
IVFD : I Nacl 3%, II futrolit, I RL(24 hours)
PRC 300cc Hb: 9 g/dl
8/10/2019 MORPOT 17.12.14
16/43
Medicamentosa :
Levofloxacin1x500mg (IV)
Paracetamol
Ca Gluconas 1 amp (IV)
Vit K 1 amp (IV)
Plasminex 2X1 amp (IV)
8/10/2019 MORPOT 17.12.14
17/43
2. Mr. O (43 years old)
Main complaint : pain in his genitalia
Secondary complaint : -
8/10/2019 MORPOT 17.12.14
18/43
History of illness
Patient came to ERS RSU UKI with main complaint
pain in his scrotum since 2 weeks ago. The pain can be
felt when patient on sit position and the scrotum was
touched. Patient didntknow caused from his complaint,
only the pain came suddenly. The pain isntcontinously
sometimes come and then not pain anymore. The pain
had not been cured before. Patient didnthave complaint
like this before and never used some drugs to reduced
his complaint.Family history : Diabetic Melitus
8/10/2019 MORPOT 17.12.14
19/43
Vital Sign
General conditions : Look mild sick
Consciousness: E4V5M6
BP : 120/90mmHg
Pulse: 102x/minute
RR: 22 x/minute
Temperature : 36,3o
C
8/10/2019 MORPOT 17.12.14
20/43
HEAD TO TOE
Head: Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm, centered,
Direct Light Reflex +/+, Indirect Light Reflex
+/+, CA -/-
Ear : Normal, LCS (-), Blood (-)
Neck : Bruise (-), Hematoma (-)
8/10/2019 MORPOT 17.12.14
21/43
Thorax :- Inspection : bruise (-), movement of chest wall
symmetrical
- Palpation : Vocal fremitus symmetrical
- Percussion : sonor right=left, percussion pain (-)
- Auscultation : basic breath sound vesicular
right=left, wh-/-, rh-/-.
8/10/2019 MORPOT 17.12.14
22/43
Abdomen :
- Inspection : flat, bulging (-)
- Auscultation : bowel sound (+) 7x/min
-Palpation : tenderness (-), defense muscular
(-), pain palpitation (-)
- Percussion : tympani, percussion pain (-)
8/10/2019 MORPOT 17.12.14
23/43
Extremities
CRT< 2, warm, sensoric (+)
8/10/2019 MORPOT 17.12.14
24/43
Locale status
Genitalia externa
Penis :
OUE : secret -, stricture -,
circumcision-, pain-,
Scrotum :
I : swelling (+) hyperemis (+), pus (+)Palpation : pain (+), dextra testis not
palpable,
8/10/2019 MORPOT 17.12.14
25/43
8/10/2019 MORPOT 17.12.14
26/43
Laboratorium
Na : 130 mmol/L
K : 4,1 mmol/L
Cl : 96 mmol/L
Hb : 11,6 gr/dl
L : 11.700/ul
Ht : 32,3 % T : 347.000/ul
GDS : 453mg/dl
8/10/2019 MORPOT 17.12.14
27/43
Urinalisa
Reduction +3
Leucocyt 4-6/LPB
8/10/2019 MORPOT 17.12.14
28/43
Working diagnose
Abses Regio
scrotalis
DM type 2
Hiponatremia Anemia
8/10/2019 MORPOT 17.12.14
29/43
Treatment Planning
Diet : biasa
IVFD
I RL
Medikamentosa Ceftriaxone 1 gr
(IV)
Tofadex 3 X 1
amp (IV)
Ranitidine 2 X 1
amp (IV)
Kompres luka
dengan Nacl
8/10/2019 MORPOT 17.12.14
30/43
TN. A ( 54th)Mechanism of the Trauma
Patient fell from motorcycle due to abrupt stop because
the car in front of him sudden break. Patient fell left
sided so the bike he ride fall on him.
Injury of target organ
Extremities
Symptoms and signs
Pain, wound, edema
Treatment Pre Hospital (-)
8/10/2019 MORPOT 17.12.14
31/43
PRIMARY SURVEY
Airway : CLEAR
Look : no obstruction
Listen : no extra breath sound (gurgling (-), snoring (-),
stridor (-)) Feel : there were warm air from both nose and mouth
Breathing : CLEAR
Inspection: bruise (-), chest wall movement
symmetrical, RR 18 x/min, hematoma ()
Pal : crepitation (-)
Per : sonor right = left
Aus : basic breath sound bronchial, rh -/-, wh -/-
8/10/2019 MORPOT 17.12.14
32/43
Circulation : No Sign Of Shock
Warm extremities
Blood pressure 120/80 mmHg
Pulse = 108 x/minute
Temp =36 0C
CRT
8/10/2019 MORPOT 17.12.14
33/43
SECONDARY SURVEY
AMPLE
Allergy : -
Medication : - Past Illness : -
Last Meal : in the evening
Event : Accident
8/10/2019 MORPOT 17.12.14
34/43
HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA -/-
Ear : Normal, LCS (-), blood (-)
Neck : Bruise (-), hematoma (-)
8/10/2019 MORPOT 17.12.14
35/43
Thorax :- Inspection : bruise (-), movement of chest wall
symmetrical
- Palpation : crepitation (-), palpation pain (-)
- Percussion : sonor right = left, percussion pain
(-)
- Auscultation: vesicular basic breathe sound
right=left, wh-/-, rh-/-.
8/10/2019 MORPOT 17.12.14
36/43
Abdomen
- Inspection : flat, bruise (-),
- Auscultation : bowel sound (+) 6x/min
-Palpation : tenderness (-),muscular
defense (-)
- Percussion : tympani, percussion
pain (-)
8/10/2019 MORPOT 17.12.14
37/43
Locale status
L : multiple lesion, swollen,
F : crepitate, pain
M : he cant lift his left leg, finger
movement (+)
CRT< 2, warm, sensoric (+)
8/10/2019 MORPOT 17.12.14
38/43
8/10/2019 MORPOT 17.12.14
39/43
History of illness
Patient brought to hospitals emergency unitbecause a motorcycle accident about an hour
before arrive at hospital. He got scratches on his
left and right palm, and his left and right lower
leg. He also have difficulty to move his leg. Thereis an open wound on his right fourth finger and
left knee. He didnt have any complain for
dizziness, feeling sick or vomiting.
8/10/2019 MORPOT 17.12.14
40/43
Lab
Hemoglobin 13.4 g/dl
Leukocyte 15.200 /uL
Hematocrite 40,1 %
Trombocyte 269.000 /uL
8/10/2019 MORPOT 17.12.14
41/43
X-RAY
8/10/2019 MORPOT 17.12.14
42/43
Working diagnosis
Close fracture intraarticular os tibia sinistra
without NVD
Multiple vulnus excoriasi
Multiple vulnus laceration
8/10/2019 MORPOT 17.12.14
43/43
TREATMENT Non Medicamentosa :
- Hospitalized pro ORIF
- Wound toilet
- Diet : Biasa
- IVFD : I RL + III amp KetorolacMedicamentosa :
- Ceftriaxone 2x1 gram
- ranitidin 2x1
Recommended