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    Morpot Yg Stress

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    Maria Tarry Mirani
    1. Mr. J, a 25-month-old male, presented after a motorcycle accident with head, left shoulder and right knee injuries. Examination found mild head injury and edema cerebri. He was treated with oxygen, IV fluids, wound care and medications before being discharged. 2. Mrs. H, a 27-year-old female, also presented after a motorcycle accident, with chin and right knee injuries. She had a laceration to her submandibular region which was cleaned and treated with antibiotics and pain medications before being sent home. 3. A 10-year-old child, R, was in a motorcycle accident and had head, left arm and bilateral knee injuries. Ex

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    Morpot Yg Stress

    Uploaded by

    Maria Tarry Mirani
    36 views51 pages
    1. Mr. J, a 25-month-old male, presented after a motorcycle accident with head, left shoulder and right knee injuries. Examination found mild head injury and edema cerebri. He was treated with oxygen, IV fluids, wound care and medications before being discharged. 2. Mrs. H, a 27-year-old female, also presented after a motorcycle accident, with chin and right knee injuries. She had a laceration to her submandibular region which was cleaned and treated with antibiotics and pain medications before being sent home. 3. A 10-year-old child, R, was in a motorcycle accident and had head, left arm and bilateral knee injuries. Ex

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    1. Mr. J, a 25-month-old male, presented after a motorcycle accident with head, left shoulder and right knee injuries. Examination found mild head injury and edema cerebri. He was treated with oxygen, IV fluids, wound care and medications before being discharged. 2. Mrs. H, a 27-year-old female, also presented after a motorcycle accident, with chin and right knee injuries. She had a laceration to her submandibular region which was cleaned and treated with antibiotics and pain medications before being sent home. 3. A 10-year-old child, R, was in a motorcycle accident and had head, left arm and bilateral knee injuries. Ex

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    36 views51 pages

    Morpot Yg Stress

    Uploaded by

    Maria Tarry Mirani
    1. Mr. J, a 25-month-old male, presented after a motorcycle accident with head, left shoulder and right knee injuries. Examination found mild head injury and edema cerebri. He was treated with oxygen, IV fluids, wound care and medications before being discharged. 2. Mrs. H, a 27-year-old female, also presented after a motorcycle accident, with chin and right knee injuries. She had a laceration to her submandibular region which was cleaned and treated with antibiotics and pain medications before being sent home. 3. A 10-year-old child, R, was in a motorcycle accident and had head, left arm and bilateral knee injuries. Ex

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    of 51

    Emergency Room

    Morning Shift
    Report
    March, 19 2013
    th

    1.Mr.J(25 month)
    PRIMARY SURVEY
    M : fell from motorcycle
    I : head,left shoulder,right knee
    S : pain
    T : Self protection:
    Patient can talk coherently
    Patient was brought by his family with car to UKI
    hospital

    Primary Survey
    Airway
    : clear
    Breathing :
    Insp : chest wall movement
    symmetrical, RR
    22 x/min,
    bruise (-)
    Pal
    : crepitation Per : sonor right = left
    Aus : Basic breath sound vesiculer

    C = cold acral, Pulse = 100/m


    ,capillary
    refill <2
    D= GCS E3M6V5, pupil isochoric 3/3
    mm,
    centered,
    direct
    light
    reflex/indirect
    light reflex +/+ ,
    lateralization (-)
    E = Theres no life threatening
    wound

    History
    of
    anamnesis) :

    illness

    (allo

    Patient came to Emergency Room UKI hospital


    after fell down from motorcycle 30 minutes before
    admittance to hospital. the patient was on
    motorcycle with speed 70km/hour. Patient avoid
    the car then fell to the left side and his left shoulder
    hit the road.his right knee was hit the road.patient
    wearing full face helm. Head impact (+), chest
    impact (-), unconciousness (+),amnesia(+), nausea
    (-), vomitus (-).

    AMPLE

    Allergy
    :Medication
    :Past Illness
    :Last Meal : 1 hours before
    admittance
    Event
    : motorcycle
    accident

    HEAD TO TOE
    General Examination
    GCS : Look moderate illness
    E4M6V5
    BP
    : 110/70 mmHg
    HR
    : 108 x/m
    RR
    :22 x /m
    T
    : 36,5 0C
    Head : Bruise Eyes : Pupil circular, isochoric 3mm/3mm,
    centered, Direct Light Reflex +/+,
    Indirect
    Light Reflex +/+

    Ear
    Neck

    : otorhhea (-)
    : Bruise (-)

    Thorax
    Insp : movement of chest wall symmetrical,
    bruise (-)
    Pal : crepitation (-)
    Per : sonor right = left
    Aus : Basic breath sound vesiculer

    Abdomen
    Ins : flat,bruise (-)
    Pal : tenderness (-)
    Per : Percusion tenderness (-),
    Tympani
    Aus : bowel sound (+) 3x/min
    Extremity :
    warm acral, cap. refill < 2

    LOCALIZED STATUS
    Regio facialis
    Look :multiple vulnus excoriasi 1x1cm, 2x2 cm,
    swollen (-), hematom (-), active bleeding (-)
    Feel : tenderness (+), crepitation (-)
    Regio genu dextra
    Look : vulnus excoariasi, 1x1 cm,swollen
    (-),haematom (-),active bleeding (-)
    Feel : tenderness (+),crepitation (-)
    Movement: active and passive movement is
    unlimited

    DIAGNOSIS
    Mild head injury + edema cerebri

    TREATMENT
    - O2 face mask 8 lpm
    - IVFD : RL
    - Wound toilet
    Mm/
    Ikaneuron 1x1
    Ergotika 2x1
    Ketorolac 1x1
    Ranitidine 2x1
    Patient was sent home

    2. Mrs. H (27 YO)


    PRIMARY SURVEY
    M : felt down from motorcycle
    I : chin, right knee
    S :pain on injury
    T : Self protection:
    Patient can talk coherently
    Patient was brought by her friend with car to UKI
    hospital

    Primary Survey
    Airway
    : clear
    Breathing :

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

    C = warm acral, Pulse = 84/m


    ,capillary
    refill <2
    D= GCS E4M6V5, pupil isochoric 3/3
    mm,
    centered,
    direct
    light
    reflex/indirect
    light reflex +/+ ,
    lateralization (-)
    E = Theres no life threatening
    wound

    History
    of
    anamnesis) :

    illness

    (allo

    Patient came to Emergency Room UKI hospital


    after felt down from motorcycle 5 minutes before
    admittance to hospital. The patient hit the cone,
    with speed 40km/hour and used helmet. The chin
    patient hit to the soil , the right knee hit to the soil .
    The patient complaint hard to speak.Head impact
    (+), chest impact (-) unconciousness (-), nausea (-),
    vomitus (-).

    AMPLE

    Allergy
    :Medication
    :Past Illness
    :Last Meal : 1 hours before
    admittance
    Event
    : hit by motorcycle

    HEAD TO TOE
    General Examination
    GCS : Look moderate illness
    E4M6V5
    BP
    : 120/80 mmHg
    HR
    : 84 x/m
    RR
    :20 x /m
    T
    : 36,6 0C
    Head : Bruise - , oedem - , Haematom - , blood Eyes : Pupil circular, isochoric 3mm/3mm,
    centered, Direct Light Reflex +/+,
    Indirect
    Light Reflex +/+

    Ear
    Neck

    : otorhhea (-)
    : Bruise (-), haematom (-)

    Thorax
    Insp : movement of chest wall symmetrical,
    bruise (-)
    Pal : crepitation (-)
    Per : sonor right = left
    Aus : Basic breath sound vesiculer right = left

    Abdomen
    Ins : flat, hematom (-), bruise (-),
    muscular
    defense (-)
    Pal : tenderness (-)
    Per : Percusion tenderness (-),
    Tympani
    Aus : bowel sound (+) 6x/min
    Extremity :
    warm acral, cap. refill < 2

    LOCALIZED STATUS
    Regio submandibularis
    Look : vulnus laceratum 4x1x0,5 cm,
    deformity(-), swollen (-), hematom (-), active
    bleeding (-)
    Feel : tenderness (+), crepitation (-)
    Regio genu dextra
    Look : vulnus ekskoriasi 3x2 cm, deformity(-),
    swollen (-), hematom (-), active bleeding (-)
    Feel : tenderness (+), crepitation (-)

    DIAGNOSIS
    Vulnus laceratum regio sub
    mentalis

    TREATMENT
    - Wound toilet
    - Hecting situation
    Mm/
    Cefixime 2x1 tab
    Ketesse 3x1 tab
    Ranitidin 2x1 tab

    3. R child ( 10 yo )
    PRIMARY SURVEY
    M : motorcycle accident
    I : head, left arm, right and left knee
    S : pain on injury
    T : antiseptic
    Self protection: use gloves
    Patient can talk coherently
    Patient was brought by car to UKI hospital

    Primary Survey
    Airway : clear
    Breathing :
    Insp : chest wall movement
    symmetrical, RR
    26 x/min,
    bruise (-), hematoma (-)
    Pal
    : crepitation Per : sonor right = left
    Aus : Basic breath sound vesiculer.

    Circulation : warm acral, Pulse =


    102/m ,
    capillary refill <2
    D = GCS E4M6V5, pupil isochoric
    3/3 mm,
    centered, direct light
    reflex/indirect
    light reflex +/+ ,
    lateralization (-)
    E = Theres no life threatening
    wound

    History of illness
    anamnesis) :

    (auto

    patient came to Emergency room UKI hospital because was hit by


    motorcycle with speed 80km/hour. Patient fell with prone
    position.Head
    impact
    (+),
    chest
    impact
    (-)
    unconciousness (-), nausea (-), vomitus (-),
    headache (+).

    AMPLE

    Allergy
    :Medication
    :Past Illness
    :Last Meal : 2 hours before
    admittance
    Event
    : motorcycle
    accident

    HEAD TO TOE
    General Examination
    GCS : Look moderete illness
    E4M6V5
    BP
    : 110/70 mmHg
    HR
    : 102/m
    RR
    : 25/m
    T
    :36,5 C
    Head : Bruise (+)
    Eyes : Pupil circular, isochoric 3mm/3mm,
    centered, Direct Light Reflex +/+,
    Indirect
    Light Reflex +/+

    Ear
    Neck

    : otorhhea (-)
    : Bruise (-)

    Thorax
    Insp : movement of chest wall symmetrical,
    bruise (-)
    Pal : crepitation (-)
    Per : sonor right = left
    Aus : Basic breath sound vesiculer

    Abdomen
    Ins : flat,bruise (-)
    Pal : tenderness (-)
    Per : Percusion tenderness (-),
    Tympani
    Aus : bowel sound (+) 4x/min
    Extremity :
    warm acral, cap. refill < 2

    LOCALIZED STATUS
    Regio frontalis dextra et sinistra
    Look : vulnus ekskoriasi 5x3 cm. bruise(-),swollen (-),
    Active bleeding,(-)
    Feel : tenderness (+)
    RegioTemporoparietal dextra et sinistra
    Look : bruise (-)
    Feel : tenderness (+),crepitation (-)
    Regio antebrachii sinistra
    Look : vulnus ekskoriasi,4x3 cm, bruise (+),active
    bleeding (-)
    Feel : tenderness (+)
    Movement : active and passive movement was unlimited

    Regio genu dextra et sinistra


    Look : vulnus ekskoriasi 4x3 cm,bruise
    (+)
    Feel : tenderness (+)
    Movement : active and passive
    movement was unlimited

    Diagnosis
    Mild Head injury

    TREATMENT
    -Wound toilet
    -Paracetamol 3x1

    3. Mr.E( 35 yo )
    PRIMARY SURVEY
    M : car accident
    I : face
    S : nose bleeding
    T :
    Self protection: use gloves
    Patient can talk coherently
    Patient was brought by car to UKI hospital

    Primary Survey
    Airway : clear
    Breathing :
    Insp : chest wall movement
    symmetrical, RR
    20 x/min,
    bruise (-)
    Pal
    : crepitation Per : sonor right = left
    Aus : Basic breath sound vesiculer.

    Circulation : warm acral, Pulse =


    82/m ,
    capillary refill <2
    D = GCS E4M6V5, pupil isochoric
    3/3 mm,
    centered, direct light
    reflex/indirect
    light reflex +/+ ,
    lateralization (-)
    E = Theres no life threatening
    wound

    History of illness
    anamnesis) :

    (auto

    30 minutes before patient came to Emergency room UKI


    hospital,patient had car accident with speed 90km/hour. Patient
    was sleepy and hit the other car in front of his car.Head impact
    (+), chest impact (-) unconciousness (-), nausea (-),
    vomitus (-), headache (-).

    AMPLE

    Allergy
    :Medication
    :Past Illness
    :Last Meal : 3 hours before
    admittance
    Event
    : car accident

    HEAD TO TOE
    General Examination
    GCS : Look moderete illness
    E4M6V5
    BP
    : 110/80 mmHg
    HR
    : 82/m
    RR
    : 20/m
    T
    :36,5 C
    Head : Bruise (-)
    Eyes : Pupil circular, isochoric 3mm/3mm,
    centered, Direct Light Reflex +/+,
    Indirect
    Light Reflex +/+

    Ear
    Neck

    : otorhhea (-)
    : Bruise (-)

    Thorax
    Insp : movement of chest wall symmetrical,
    bruise (-)
    Pal : crepitation (-)
    Per : sonor right = left
    Aus : Basic breath sound vesiculer

    Abdomen
    Ins : flat,bruise (-)
    Pal : tenderness (-)
    Per : Percusion tenderness (-),
    Tympani
    Aus : bowel sound (+) 4x/min
    Extremity :
    warm acral, cap. refill < 2

    LOCALIZED STATUS
    Regio nasal
    Look : swollen (+),hematom(-)active bleeding(-)
    Feel : tenderness (+)

    Diagnosis
    Mild Head injury

    TREATMENT

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