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    Morning Shift Report: Emergency Room

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    Iputu Abhi Acarya Saputra
    A 25-year-old male patient was brought to the emergency room after a motorcycle accident. He had injuries to his right and left hands and right knee but was conscious and coherent. On examination, he had bruising and wounds on his hands and knee but no other serious injuries. X-rays showed a closed intra-articular fracture of the left radius bone without major vessel damage. He was diagnosed with excoriation wounds on both hands and right knee and given medications for pain and wound healing.

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    Morning Shift Report: Emergency Room

    Uploaded by

    Iputu Abhi Acarya Saputra
    47 views11 pages
    A 25-year-old male patient was brought to the emergency room after a motorcycle accident. He had injuries to his right and left hands and right knee but was conscious and coherent. On examination, he had bruising and wounds on his hands and knee but no other serious injuries. X-rays showed a closed intra-articular fracture of the left radius bone without major vessel damage. He was diagnosed with excoriation wounds on both hands and right knee and given medications for pain and wound healing.

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    A 25-year-old male patient was brought to the emergency room after a motorcycle accident. He had injuries to his right and left hands and right knee but was conscious and coherent. On examination, he had bruising and wounds on his hands and knee but no other serious injuries. X-rays showed a closed intra-articular fracture of the left radius bone without major vessel damage. He was diagnosed with excoriation wounds on both hands and right knee and given medications for pain and wound healing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    47 views11 pages

    Morning Shift Report: Emergency Room

    Uploaded by

    Iputu Abhi Acarya Saputra
    A 25-year-old male patient was brought to the emergency room after a motorcycle accident. He had injuries to his right and left hands and right knee but was conscious and coherent. On examination, he had bruising and wounds on his hands and knee but no other serious injuries. X-rays showed a closed intra-articular fracture of the left radius bone without major vessel damage. He was diagnosed with excoriation wounds on both hands and right knee and given medications for pain and wound healing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 11

    Emergency Room

    Morning Shift Report


    May , 31st 2013

    Mr. G ( 25 YO)
    M : motor cycle accident I : regio dorso manus dextra and sinistra S : vulnus eksoriasi et dorso manus dextra and sinistra, patela dextra T: -

    Primary Survey Airway : Clear


    Breathing :

    Insp : bruise (-), chest wall movement symmetrical, RR 18 x/ min, hematoma (-) Pal : crepitation sub cutis (-) Per : sonor right = left Aus : Basic breath sound vesicular right = left

    C = warm extremities, Pulse = 88 bpm, BP 110/70 mmHg, capillary refill time <2

    D = GCS E4M6V5, pupil isochors 3mm/3mm, centered, direct light reflex/ indirect light reflex +/+
    E = there is no life threatening wound

    History of illness :
    Patient came to the RSU UKI with police because the patient had a traffic accident. The patient fell down from his motor cycle with the left arm as a . After he fell there was no active bleeding, no loss of consciousness, no vomitting, theres no head injury. Patient can talk coherently in long sentence and walk by himself to the hospital. Patient already went to the clinic and has been given medication to heal his headache.

    SECONDARY SURVEY
    HEAD TO TOE
    Eyes

    : pupil isochors 3mm/3 mm, centered, direct light reflex/ indirect light reflex +/+ Ear : Bruise (-), hematoma (-) Neck : Bruise (-), hematoma (-) Thorax :

    Insp Pal Per Aus

    : bruise (-), movement of chest wall symmetrical : crepitation (-), tenderness (-) : sonor right = left : Basic breath sound vesicular right = left

    Abdomen :

    : flat, bruise (-) Aus : bowel sound (+) 6x/min Pal : Supel, tenderness (-), muscular defense (-) Per : tympani Extremity: Warm extremities, cap. refill time < 2, edema (-)

    Ins

    Localized Status
    Regio Manus Dextra

    Insp : bruise (+), active bleeding (-) Pal : crepitation (-), tenderness (-) Move : can palmar flexion, dorso flexion, ulnar flexion, radier Insp : bruise (+), active bleeding (-), oedem (+) Pal : crepitation (-), tenderness (+) Move : cant palmar flexion, dorso flexion, ulnar flexion, radier Insp : bruise (+), active bleeding (-) Pal : crepitation (-), tenderness (-) Move : can palmar flexion, dorso flexion, ulnar flexion, radier

    Regio Manus Sinistra


    Regio Genu Dextra


    Diagnosis
    Fr. Os radius sinistra intra artikular tertutup

    tanpa gangguan NVD


    Vulnus Eksoriasis dorso manus dextra-

    sinistra, dan patela dextra

    TREATMENT
    Sporetik 2x100 mg
    Analgetik 3x1 Oscal 2x1 Tab

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