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    Morning Shift Report: Emergency Room

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    Ferdy Erawan
    1. Child A was brought in with an axillary wound from falling on a fence. Exam found a 2cm wound with pain but no other issues. The wound was cleaned and closed. 2. Mr. S was in a motorcycle accident and had an open fracture to his right second toe. His foot was splinted and he was given antibiotics and pain medication. 3. Mr. I was hit by a motorcycle and had right hip pain and difficulty breathing. Exam found bruising to his right chest but no other injuries. He was given oxygen and pain medication.

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    Morning Shift Report: Emergency Room

    Uploaded by

    Ferdy Erawan
    16 views43 pages
    1. Child A was brought in with an axillary wound from falling on a fence. Exam found a 2cm wound with pain but no other issues. The wound was cleaned and closed. 2. Mr. S was in a motorcycle accident and had an open fracture to his right second toe. His foot was splinted and he was given antibiotics and pain medication. 3. Mr. I was hit by a motorcycle and had right hip pain and difficulty breathing. Exam found bruising to his right chest but no other injuries. He was given oxygen and pain medication.

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    1. Child A was brought in with an axillary wound from falling on a fence. Exam found a 2cm wound with pain but no other issues. The wound was cleaned and closed. 2. Mr. S was in a motorcycle accident and had an open fracture to his right second toe. His foot was splinted and he was given antibiotics and pain medication. 3. Mr. I was hit by a motorcycle and had right hip pain and difficulty breathing. Exam found bruising to his right chest but no other injuries. He was given oxygen and pain medication.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    16 views43 pages

    Morning Shift Report: Emergency Room

    Uploaded by

    Ferdy Erawan
    1. Child A was brought in with an axillary wound from falling on a fence. Exam found a 2cm wound with pain but no other issues. The wound was cleaned and closed. 2. Mr. S was in a motorcycle accident and had an open fracture to his right second toe. His foot was splinted and he was given antibiotics and pain medication. 3. Mr. I was hit by a motorcycle and had right hip pain and difficulty breathing. Exam found bruising to his right chest but no other injuries. He was given oxygen and pain medication.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 43

    Emergency Room

    Morning Shift Report


    May , 29th 2013
    1. Child A (7 YO)
    M : Fell on the fence
    I : mid axilla dextra
    S : Pain
    T : betadine and closed the wound by verban
    Primary Survey
    Airway : Clear ( snoring -, gurgling -, stridor - )
    Breathing :
    Insp: bruise (-), chest wall movement
    symmetrical right and left, RR 20 x/ min,
    hematoma (-)
    Pal: crepitation sub cutis (-)
    Per : sonor right = left
    Aus : Basic breath sound vesicular
    C = warm extremities, Pulse = 60bpm, BP
    90/70 mmHg, capillary refill time <2
    D = GCS E4M6V5, pupil isocors 3mm/3mm,
    centered, direct light reflex/ indirect light
    reflex +/+
    E = there is no life threatening wound
    History of illness :
    Patient came to RS UKI with wound below the right
    arm pit approximately 3 hours before entering the
    hospital. On patient we found open wound at right
    arm pit. After the incident patient went to the
    nearest clinic and was given bethadine and closed by
    verban after that the patient came to RSU UKI.
    SECONDARY SURVEY
    HEAD TO TOE
    Eyes: pupil isocors 3mm/3 mm, centered, direct light
    reflex/ indirect light reflex +/+
    Ear: Bruise (-), hematoma (-)
    Neck : Bruise (-), hematoma (-)
    Thorax:
    Insp : bruise (-), movement of chest wall
    symmetrical
    Pal : crepitation (-), tenderness (-)
    Per : sonor right = left
    Aus: Basic breath sound vesicular
    Abdomen :
    Ins: flat, bruise (-)
    Aus: bowel sound (+) 6x/min
    Pal: Supel, tenderness (-), muscular
    defense (-)
    Per: tympani
    Extremity:
    Warm extremities, cap. refill time < 2,
    edema (-)
    Localized Status

    Regio Mid Axillaris dextra


    Insp : bruise (-), active bleeding (-) Wound L =
    2cm ,width: 1 cm , base of wound: subcutis,
    Pal : crepitation (-), tenderness (-)
    Diagnosis
    Vulnus lacertum regio mid axillaris
    detra
    TREATMENT

    Hecting

    MM/ : 1.Analgetik
    2.Vitamin supplement
    2. Mr. S (55 YO)

    M : motorcycle accident
    I : right foot finger
    S : pain, active bleeding (-)
    T:-

    12
    Primary Survey
    Airway : Clear ( snoring -, gurgling -, stridor - )
    Breathing :
    Insp: bruise (-), chest wall movement symmetrical,
    RR 20 x/ min, hematoma (-)
    Pal: crepitation sub cutis (-)
    Per : sonor right = left
    Aus : Basic breath sound vesicular
    C = warm extremities, Pulse = 80 bpm, BP
    160/90 mmHg, capillary refill time <2
    D = GCS E4M6V5, pupil isocors 3mm/3mm,
    centered, direct light reflex/ indirect light
    reflex +/+
    E = there is no life threatening wound
    Present illness
    Patients come to the RSU UKI because the wound at
    right foot finger.The wound caused by a motorcycle
    accident, 15 minutes before admited to the RSU
    UKI. According patient, he hit by car on his right
    side. He felt sick at right foot.
    HEAD TO TOE
    Eyes: pupil isochors 3mm/3 mm, centered, direct light
    reflex/ indirect light reflex +/+
    Ear: Bruise (-), hematoma (-)
    Neck : Bruise (-), hematoma (-)
    Thorax:
    Insp : bruise (-), movement of chest wall symmetrical
    Pal : crepitation (-), tenderness (-)
    Per : sonor right = left
    Aus: Basic breath sound vesicular

    16
    Abdomen:
    Ins: flat, bruise (-)
    Aus: bowel sound (+) 8x/min
    Pal: Supel, tenderness (-), muscular
    defense (-)
    Per: tympani

    17
    Status localized :
    Regio pedis dextra
    I : bruise (-), active bleeding (-) Wound: vulnus ekskoriasi ,
    base of wound: bone,
    P: crepitation (+), tenderness (-)
    Diagnosis
    Open Fracture grade 3B digiti II
    proximal phalanx os pedis dextra

    21
    TREATMENT

    Hecting and Splint


    Mm / antibiotic 2x1 tab
    analgesic 3x1 tab 3

    22
    1. Mr. I (24 YO)
    M : Hit by motorcycle
    I : right hip
    S : Pain
    T:-
    Primary Survey
    Airway : Clear ( snoring -, gurgling -, stridor - )
    Breathing :
    Insp: bruise (-), chest wall movement
    symmetrical right and left, RR 28 x/ min,
    hematoma (-)
    Pal: crepitation sub cutis (-)
    Per : sonor right = left
    Aus : Basic breath sound vesicular
    C = warm extremities, Pulse = 60bpm, BP
    160/90 mmHg, capillary refill time <2
    D = GCS E4M6V5, pupil isocors 3mm/3mm,
    centered, direct light reflex/ indirect light
    reflex +/+
    E = there is no life threatening wound
    History of illness :
    Patient was dropped at RSU UKI because he got an
    accident. A few moment before entering the
    hospital the patient was crossing on the street and
    was hit by a motorcycle from the right side. Patient
    came with complain of pain on the right hip and
    difficulty to breath. Nausea (-), vomiting (-),
    unconciousness.
    SECONDARY SURVEY
    HEAD TO TOE
    Eyes: pupil isocors 3mm/3 mm, centered, direct light
    reflex/ indirect light reflex +/+
    Ear: Bruise (-), hematoma (-)
    Neck : Bruise (-), hematoma (-)
    Thorax:
    Insp : bruise (+) at right chest wall , movement of
    chest wall symmetrical
    Pal : crepitation (-), tenderness (-)
    Per : sonor right = left
    Aus: Basic breath sound vesicular
    Abdomen :
    Ins: flat, bruise (-)
    Aus: bowel sound (+) 6x/min
    Pal: Supel, tenderness (-), muscular
    defense (-)
    Per: tympani
    Extremity:
    Warm extremities, cap. refill time < 2,
    edema (-)
    Diagnosis
    Contutio soft tissue
    TREATMENT

    1. O2 5lpm
    2. Analgetik 3x1 tab
    2. Mr. J (55 YO)

    M : fell down the stair from 2nd floor


    I : Back head
    S : pain, active bleeding (-)
    T:-

    33
    Primary Survey
    Airway : Clear ( snoring -, gurgling -, stridor - )
    Breathing :
    Insp: bruise (-), chest wall movement symmetrical,
    RR 20 x/ min, hematoma (-)
    Pal: crepitation sub cutis (-)
    Per : sonor right = left
    Aus : Basic breath sound vesicular
    C = warm extremities, Pulse = 104 bpm, BP
    120/90 mmHg, capillary refill time <2
    D = GCS E4M6V5, pupil isocors 3mm/3mm,
    centered, direct light reflex/ indirect light
    reflex +/+
    E = there is no life threatening wound
    Present illness
    Patients come to the RSU UKI because the wound
    on the back of his head . The wound was caused
    because he fell down from the stair from 2nd floor,
    15 minutes before admitted to the RSU UKI.
    According to the patient, he consumed alcohol. The
    patient also has exoriation on left eye brow. Nausea
    (-) vomiting (-) unconciouness (-)
    HEAD TO TOE
    Eyes: pupil isochors 3mm/3 mm, centered, direct light
    reflex/ indirect light reflex +/+
    Ear: Bruise (-), hematoma (-)
    Neck : Bruise (-), hematoma (-)
    Thorax:
    Insp : bruise (-), movement of chest wall symmetrical
    Pal : crepitation (-), tenderness (-)
    Per : sonor right = left
    Aus: Basic breath sound vesicular

    37
    Abdomen:
    Ins: flat, bruise (-)
    Aus: bowel sound (+) 8x/min
    Pal: Supel, tenderness (-), muscular
    defense (-)
    Per: tympani

    38
    Status localized :
    Regio Capitis
    I : bruise (-), active bleeding (-) Wound: , base of wound:
    P: crepitation (- ), tenderness (-)
    Diagnosis
    Mild Head injury
    Intoxication of alcohol

    42
    TREATMENT

    Betadine and closed by verban


    Mm / antibiotic 2x1 tab
    brain stimulator 3x1 tab 3

    43

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