Emergency Unit

Night Shift Report

23rd January 2014

Trauma : 2
Non trauma : -

1. Mrs. E.P (44 Y.O.)

M: The patient had an motorcycle
accident and falled to the left side
I: oedem in anterio-axilaris dextra
line
S: dipsnoe
T: 1st aid in premier jt.negara
hospital - Asering 500ml, tranexamic
acid 3x250mg

PRIMARY SURVEY
Airway : Clear
Breathing :
Insp : symmetrical movement of chest wall, bruise (-),
RR : 39x/mins
Pal : VF right = left, crepitation (-),
pain on palpation (-)
Per : sonor right = left, pain on percussion (+/-)
Aus : vesicular basic breath sound, wh -/-, rh-/-

PRIMARY SURVEY

C = Warm extremities, Pulse = 102x/min ,

BP =180/110 mmHg, temperature = 37.5 C,
capillary refill < 2
D = GCS 13 E3V4M6 , pupil isochoric 3 mm / 3
mm, direct light reflex/indirect light reflex +/+,
lateralization (-)
E = Life threatening wound and bruise

 Chief complain
: dispnoe
Additional complain : pain in right regio of
thorax

 History of Illness :
Patient came to UKI hospital with dispnoe.
The patient got an acident 3 days ago n was
treated in jt.negara premier hospital. The patient
was in motorcycle accident becouse he wasnt
saw the hole in the street. The patient wear full
helmet and was 60km/h in speed.

SECONDARY SURVEY
HEAD TO TOE
General Examination
Head : Bruise (-) , edema (-) tumor (-), wound (+) :
regio peri oral
Eyes : Round shaped pupil, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect Light
Reflex +/+, CA-/-, SI-/Neck : Bruise (-), hematoma (-), no palpable
enlargement on regional lymph nodes

Thorax
Insp : Symmetrical movement of chest wall,
bruise (+)
Pal : VF right = left, crepitation (-),
pain on palpation (+)
Per : sonor right = left, percussion pain (+/-)
Aus : vesicular basic breath sound, wh -/-, rh-/-

Abdomen
Insp : flat, hematoma (-), bruise (-),
muscular defense (-), scars (+)
Palp : smooth, no palpable enlargement on
hepar and spleen
Perc : Tympani, pain on percussion (-)
Ausc : bowel sound (+) 4x/min
Extremities
cap. refill < 2, warm extremity, edema (-),
bruise (+) regio superior extemitas,
hematoma (-)

AMPLE
Allergy
: Medication : Past Illness : thorax traumatic history,
hipertension, laparotomi e.c apendicity
Last Meal
: 1.pm
Event
: Had motorcyles accident

Finger in every orifices

Nose
Ear
Mouth
Anus
OUE

: Blood (-), LCS (-)

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

X-ray

DIAGNOSIS

Emphysema Subcutis + Fracture costae + simple

pneumothorax

TREATMENT
Non Medikamentosa
- hospitalize
- Wound toilet
- IVL
Medications:
- kotorolac
- Ikaneuron
- Ergotika
- Terpasef

Mr. A (35 y.o)

M : motorcycle accident crashed with
car
I : wound at bilateral antebrachii ,
genu sinistra, bilateral pedis
S : pain
T:-

PRIMARY SURVEY
Airway : Clear

Breathing :
Insp : symmetrical movement of chest wall,
bruise (-),
RR : 20x /mins
Pal : VF right = left, crepitation (-),
pain on palpation (-)
Per : sonor right = left, pain on percussion (-/-)
Aus : vesicular basic breath sound, wh -/-, rh-/-

PRIMARY SURVEY
C = Warm extremities, Pulse = 82x/min ,

BP =130/70 mmHg, temperature = 37 C,

capillary refill < 2
D = GCS 15 E4M6V5 , pupil isochoric 3 mm / 3
mm, direct light reflex/indirect light reflex +/+,
lateralization (-)
E = No Life threatening wound and bruise

 Chief complaint : wound after motorcycle

accident
Additional complaint : pain

History of Illness
Patient came to UKI after got a motorcycle
accident 15 minutes before. The patient use
helm, unfortunately got crashed with the car
behind his motorcycle and then he dropped to
the street. His head was still with the helm.
He drove the motorcycle 80 km/hours. There
was wound at his feet, hands, and knee.
Patient also felt the pain after accident.

SECONDARY SURVEY
HEAD TO TOE

General Examination
Head : Bruise (-) , edema (-) tumor (-), wound (-)
Eyes : Round shaped pupil, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect Light
Reflex +/+, CA-/-, SI-/Neck : Bruise (-), hematoma (-), no palpable
enlargement on regional lymph nodes

SECONDARY SURVEY
Thorax
Insp : Symmetrical movement of chest wall,
bruise (-)
Pal : VF right = left, crepitation (-),
pain on palpation (-)
Per : sonor right = left, percussion pain (-/-)
Aus : vesicular basic breath sound, wh -/-, rh-/-

Abdomen
Insp : flat, hematoma (-), bruise (-),
muscular defence (-), scars (-)
Palp : smooth, no palpable enlargement on hepar
and spleen
Perc : Tympani, pain on percussion (-)
Ausc : bowel sound (+) 7x /min

 Extremities
1. Regio cubiti dextra :
L : wound (+), dirty, basic : subcutis
F : crepitation (-), pain in palpation (+)
M : limited in motion

 2. Regio cubiti dextra

L : wound (+), dirty, basic wall subcutis ,
3x2 cm
F : crepitation (-), pain in palpation (+)
M: no limitation

 3. Regio Genu sinistra

L : wound (+), dirty, basic wall subcutis ,
F : crepitation (-), pain in palpation (+)
M: no limitation

 3. Regio Genu dextra

L : wound (+), dirty, basic wall subcutis ,
F : crepitation (-), pain in palpation (+)
M: no limitation

 5. Regio Pedis dextra

L : wound (+), dirty, basic wall ; subcutis
F : crepitation (-), pain in palpation (+)
M : no limitation but pain

 6. Regio Pedis sinistra

L : wound, dirty, basic subcutis
F : crepitation (-)
M : no limitation but pain