EMERGENCY CASE REPORTJuly 26th 2011ER physician : Budi, MD
Supervisor : Iwan, MD, Surgeon
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IDENTITY Name Age : Mrs. M : 23 years old : Saturday, July 23th
2011, 18.00 Time of the event Sent by : taxi
Time of admission : Saturday, July 23th 2011, 18.15 Prehospital
treatment : - Chief complaint : o Pain at right leg Additional
complainto Open wound on right leg
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universal precautions : latex gloves
PRIMARY SURVEY
Airway with cervical control
A. B.
Cervical Immobilization:1. Collar :2. LSB :-
Airway AssesSuction Guedel Endotrakeal :::-
Patient can talk clear and spontaneously Airway Clear 18.16
Breathing and VentilationLook Spontaneus breathing deformity ,
retraction , symmetrical hemithorax movement Cyanosis -, difficulty
in breathing Feel Air blown from nose Listen Vesiculair, rhonci
-/-, wheezing -/ RR= 24x/min Breathing clear : 18.17
CirculationASSES : Pulse : 84 X / mnt Blood Pressure : 110/70
mmHg Signs of shock : (-)
Circulation clear : 18.20
DisabilityGCS :E4M6V5 = 15 since arrival Pupil :Symmetric,
round, 3mm/3mm, Light Reflex +/+ Motoric : 5555 5555 ???5 5555
Exposure Axilar temperature : 36,9 C
SECONDARY SURVEY
History of present illness 20 minutes before the admission
patient has an accident when she was walking across the street, a
motorcycle bumped her and she fell at her left side limb hiting the
asphalt first The motorcycle scratched her right leg so theres an
open wound on her right leg After the event she complained the pain
on right leg and it got worse when it being moved
History Taking Alergic : denied Medication : denied Past illness
: denied Last meal : 2 hrs before admission Event : accident
Physical Examination General condition : in pain. Consciousness
: GCS 15, E4M6V5 BP : 110/70 mmHg Pulse : 84 bpm RR : 24 x/m
Temperature : 36.9 C
Physical Examination (2)
HEADEyes : conjunctiva not anemic, sclera not icteric, isocor ,
round, 3 / 3 mm , light reflex + /+ Nose, mouth, ears within normal
limit Neck : trachea in the middle, no lymph node palpable
Physical Examination (3)
Thorax
Pulmo
Cor
: symmetric in static and dynamic, Inspection swelling(-),
hematome(-), open wound(-) : left and right stem fremitus equal,
Palpation crepitation (-) : sonor on both side Percusion
Auscultation : vesicular, rhonki -/- , wheezing -/ Inspection :
ictus cordis not seen : ictus cordis palpable at ICS V left
Palpation midclavicular line Percussion :
Left : left midclavicular line Upper : ICS II Right : right
sternal line : heart sound regular, murmur (-), gallop Auscultation
(-)
Physical Examination (4)
Abdomen: Inspection : convex, no lesion Auscultation : Bowel
sound +; 6 x/min Palpation : tender, pain (-) , liver and spleen
arent palpable Percussion : tympanic in all quadrant
Pelvic : deformity (-), pain (-) Genital : not checked
Extremities upper, lowerleft : within normal limit
Right Leg I : Visible deformity of the right leg(+), swelling
(+), blood (-), hematom (-)
Local status
An open wound 17cm x 15cm x 3cm on right leg, irregular shaped,
irregular border, muscle based, pain (+), bleeding (+)
(-)
P : Tenderness (+), crepitation (+), ROM limited, warm,
cap.refill
