EMERGENCY ROOM

MORNING
REPORT
Desember, 2th 2012

1 trauma patients
0 non trauma patients

1. Mr R ( YO)
M: crushed by car
I : digiti I regio pedis dextra
S: pain
T: car

PRIMARY SURVEY

Airway :snooring (-), gargling (-), stridor (-)

Conclusion : airway clear

Breathing
Inspection : bruise (-), chest wall movement
symetrical,
RR 28 times/minute
Palpation
: crepitation (-/-), VF right=left
Percusi
: sonor +/+ ,
Auscultation : Basic breath sound vesiculer +/+
Conclusion : breathing clear

Primary survey
Circulation

: warm extremities,
Pulse = 64x/mnt ,
BP:
130/80mmHg, Temp= 36,70C,
capillary refill <2
Conclusion : no sign of
shock

Disability
GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm,
centered, direct light reflex +/+ , indirect light reflex
+/+
Conclusion : no head injury

Exposure
life threatening wounds

History of illnes

30 minutes before admitted to the hospital the

patient was riding a motorcycle, when he is at traffic
light,his foot crush by a car. Head impact - ,
abdominal impact -, chest impact -, nausea -,
vomiting -, headhache -, amnesia- was, faint - .

Secondary survey
HEAD TO TOE
digiti I regio pedis dextra :
Look : vulnus ekskoriasi 5x3cm, swelling (+), bruise
(-), active bleeding (+)
Feel : pain (+)
Regio antebrachii :
Look : vuknus ekskoriasi , clot +, active bleeding Feel : pain (+)

Abdomen :
Ins
: Flat, bruise (-)
Aus : Bowel sound (+) 4x/min
Pal
: Defence muscular (-)
Per : Tympani, percussion pain (-)

AMPLE
Allergy : Medication : Past illnes : Last meal : 3 hours ago
Event : crushed by car

WD

Traumatic amputation + fraksi

microformed tibia dextra

Teraphy
Wound toilet
Hecting
Gips backslap
Mm : Antibiotik
Analgetik
Ranitidine

2. Mr.A ( 27 YO)

Chief complaint : Pain on right lower abdominal

Additional complaint : nausea, vomiting, difficult to
defecating

History
of
anamnesis) :

illness

(auto

Approximately 1 month before admittance to the

hospital, patient complained that he feels pain in his
right lower abdominal. This pain feels continously and
didnt spread to another area of abdomen. This pain is
relieved by change posisition when he lay down.
Before that he admitted that she used to feel pain at
the epigastric regio sometimes with nausea . Urinating
problem denied, defecating problem he was complaint
difficult to defecate for about 1 month ago,blood - ,
vomitus denied, fever denied.

1 day before admitted to the hospital his complaint

pain on right lower abdominal. This complaint more
severe than before. She complaint nau vomiting + 2
times that contains fluid.and he got fever , the patient
didnt check the temperature, and he went to clinic and
he has given medicine for his pain.

General Examination
General Condition : Moderate
illness
Consciousness : Compos mentis
Blood Pressure : 190/110 mmHg
Heart Rate
:80 times/minute,
aritmia
Resp. Rate
:24 times/minute
Temperature :36.8C
Anal Temperatur : 37C

GENERAL EXAMINATION
Eyes
Ear
Nose

: conjuntiva anemis -/-, sclera icteric -/: normotia/normotia, secret -/: secret -/-

Neck

: no enlarged lymph glands

Thorax :
Insp
:
symmetrical
Pal
:
Per
:
Aus
:

movement

of

chest

wall

vocal fremitus right = left

sonor right = left
vesiculer, rhonki -/-, wheezing -/-

Abdomen :
Ins
Aus
Pal
Per

:
:
:
:

flat, bruise (-)

bowel sound (+) 3times/minute
tenderness (+) in McBurney point
tympani, percussion pain (-)

Ekstremitas :
warm extremities, cap. refill < 2, edema (-)

Local status

Abdomen :

Right Lower abdominal pain, Tenderness(+) in ,Mc

BURNEY Point(+) Psoas Sign (+), Rovsing sign(-)
Obturator sign (-),Percussion Pain (-).

DIGITAL RECTAL EXAMINATION

Inspetion R. Anal : the colour same with around,
skin tag (-), fissura (-), fistel (-)
Palpation :

TSA

: Clamp
Ampula recti : Not collaps
Mucosa Retum : slippery
Pain : + on 9 10 0clock
Handscoon : Fesses (-), blood (-)

Laboratorium
Laboratory examination

Hb
: 14,9 mg/dL
Leukosit : 13,5 thousand /uL
Ht
: 45,8 %
Trombosit : 211 thousand/uL

clinical chemistry
Ureum
: 80
Na = 148
Creatinin
: 1,32 K = 2,8
GDS
: 124 Cl = 101

DIAGNOSIS
Apendisitis Cronis acute
exacerbation

TREATMENT

Patient hospitalized
Pro appendectomy
Antibiotik
H2 reseptor antagonist

3. Mrs A (58YO)
M : fall when walking to bathroom
I : regio palbebra superior et inferior sinistra,
regio buccal sinistra, regio maxilla sinistra.
S : pain on wound
T : car

PRIMARY SURVEY

Airway :snooring (-), gargling (-), stridor (-)

Conclusion : airway clear

Breathing
Inspection : bruise (-), chest wall movement
symetrical,
RR 22 times/minute
Palpation
: crepitation (-/-), VF right=left
Percusi
: sonor +/+ ,
Auscultation : Basic breath sound vesiculer +/+
Conclusion : breathing clear

Primary survey
Circulation

: warm extremities,
Pulse = 80x/mnt ,
BP:
220/110mmHg, Temp= 36,80C,
capillary refill <2
Conclusion : no sign of
shock

Disability
GCS 15 (E4M6V5) pupil isochoric 3 mm/3 mm,
centered,
direct light reflex +/+ , indirect
light reflex
+/+ , bruise (+)
at regio
periorbital sinistra, regio buccal sisnistra and
regio maxilla sinistra
Conclusion : head injury

Exposure
no life threatening wounds

History of illnes

1 day before admitted to the hospital, when the

patient was walking to the bathroom when she
suddenly slipped and fell. Head impact +
,bruises(+),than patient feel sweeling in her face.
abdominal impact -, chest impact -, nausea -,
vomiting -, headhache -, amnesia- , faint .

Secondary survey
HEAD TO TOE
Regio periorbita sinistra
Look : swelling (+), bruise (-), active bleeding (-)
Feel : pain (+)
Regio buccal sinistra
Look : swelling (+), bruise (-),excoriation(+)
active bleeding (-)
Feel : pain (+), krepitasi (+)
Regio maxilla :
Look : swelling (+), bruise (-) active bleeding +
Feel : pain (+)

Abdomen :
Ins
: flat, bruise (-)
Aus : bowel sound (+) 4x/min
Pal
: defence muscular (-)
Per : tympani, percussion pain (-)

AMPLE
Allergy : Medication : captopril
Past illnes : hyistory of hypertension
Last meal : 3 hours ago
Event : slipped ang fell down.

Toraks

WD

ICH + Ventrikulmegali + Hematom regio orbita

zygoma labialis sinistra + hipertensi heart disease

5. Mr.S ( 27 YO)

Chief complaint : Pain on right lower abdominal

Additional complaint : nausea, vomiting, difficult to
defecating

History
of
anamnesis) :

illness

(auto

Approximately 4 days before admittance to the

hospital, patient complained that he feels pain in his
right lower abdominal. This pain feels like stabbed,
continously and didnt spread to another area of
abdomen. This pain is relieved by change posisition
when he lay down. Before that he admitted that he
used to feel pain at the epigastric regio sometimes
with nausea . Urinating problem denied, defecating
problem he was complaint difficult to defecate since
about 2 day ago, vomitus denied, fever denied.

1 day before admitted to the hospital his complaint

pain on right lower abdominal. This complaint more
severe than before. He complaint nausea, vomiting + 2
times that contains fluid.and he got fever , the patient
didnt check the temperature, and he went to clinic and
he has given medicine for his pain.

General Examination
General Condition : Moderate
illness
Consciousness : Compos mentis
Blood Pressure : 150/100 mmHg
Heart Rate
:88 times/minute
Resp. Rate
:20 times/minute
Temperature :36.8C
Anal Temperatur : 37C

GENERAL EXAMINATION
Eyes
Ear
Nose
Neck

: conjuntiva anemis -/-, sclera

icteric -/: normotia/normotia, secret -/: secret -/: no enlarged lymph glands

Thorax :
Insp :movement
of
chest
wall
symmetrical
Pal
: vocal fremitus right = left
Per
: sonor right = left
Aus : vesiculer, rhonki -/-, wheezing
-/

Abdomen :
Ins
Aus
Pal
Per

:
:
:
:

flat, bruise (-)

bowel sound (+) 3times/minute
tenderness (+) in McBurney point
tympani, percussion pain (-)

Ekstremitas :
warm extremities, cap. refill < 2, edema (-)

Local status

Abdomen :

Right Lower abdominal pain, Tenderness(+) in ,Mc

BURNEY Point(+) Psoas Sign (+), Rovsing sign(-)
Obturator sign (-),Percussion Pain (-).

DIGITAL RECTAL EXAMINATION

Inspetion R. Anal : the colour same with around,
skin tag (-), fissura (-), fistel (-)
Palpation :

TSA

: Clamp
Ampula recti : Not collaps
Mucosa Retum : slippery
Pain : Handscoon : Fesses (-), blood (-)

DIAGNOSIS
Susp Apendisitis acute

TREATMENT
Patient hospitalized
Antibiotik
H2 reseptor antagonist