Download - Morpot 15 Des 2014
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Asisstant:
Dr.Kezia / DR. AGUNG AJI / dr.Benny
Co.asisstant:
Samuel Keryanto (!ie"#
$andu %aryo Jatmi&o
'aria in))ar $rati*i
Santi 'asneno
Natas!a Cinta +ins&i
,ilona De-ina
omi &o $rasetyo
Night Shift Report
Deem0er 12t!
3412
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rauma:
Non5rauma: 1
%os6italize: 3
Non5%os6italize: 7
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1. 'r. J (72 years old#
• Mechanism of trauma :-
• Injury organ : left kidney
• Signs and symptoms : 6ain
• Treatment pre hospital : 5
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PRIMAR S!R"#
• Air*ay : $%#AR
• oo& : no o0strution• isten : no e8tra 0reat! sound• 9eel : t!ere *ere *arm air "rom 0ot! nose and mout!
• Breat!in) : $%#AR• Ins : !est *all mo-ement symmetrial RR 318/min
0ruise (5# !ematoma (;#• $al : -oal "remitus symmetrial• $er : sonor ri)!t < le"t• Aus : 0asi 0reat! sound -esiular r! 5/5 *! 5/5
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• Cirulation : No Sign &f Shock • ,arm e8tremities B$ : 134/=4
• $ulse < =4 8/menit• RR : 1> 8
• em6 < 7>>4C
• CR ?3@
•Disa0ility• GCS 1 (2'>+#
6u6il iso!ori 7/7 mm entered
• Diret li)!t ree8/indiret li)!t ree8 /
•
86osure !ere *as no li"e t!reatenin) *ounds
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S#$&N'AR S!R"#
AMP%#
• Aller)y : 5
• 'ediation : 5• $ast Illness : 5
• ast 'eal : In t!e a"ternoon
• -ent : 5
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(istory of illness
$atient male 72 years old ame to t!e RRSU UKI at 12.44 ,IB *it! om6lain o" 6ainon su6ra6u0i area sine 1 *ee& a)o. !e6ain s6reads "rom !is su6ra6u0i area to t!ele"t side o" !is 0a&. %e also !as om6laintsa0out t!e red olour o" !is urine *!i! onlyours one in a *!ile and most reently 7days a)o untill today and 6ain on urination.
%e did not see& !el6 to a !ealt! 6roesionalnor did !e onsume any mediation toredue !is om6laints.
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General status
• 5GCS 1 &om6osmentis
• B$ : 134/=4
• $ulse < =4 8/menit
• RR : 1> 8
• em6 < 7>>4C
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(#A' T& T
(ead : Normoe6!aly
#yes : $u6il irular iso!ori
7mm/7mm entered Diret i)!t Ree8/ Indiret i)!t Ree8 / CA 5/5
#ar : Normal Blood (5#
Neck : Bruise (5# %ematoma (5#
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Thora) :5 Ins6etion: 0ruise (5# mo-ement o" !est
*all symmetrial
5 $al6ation : +oal "remitus symmetrial
5 $erussion : sonor ri)!t
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A*domen :
5Ins6etion : at
5Ausultation : 0o*el sound (# 28/min
5$al6ation : tenderness (5# de"ensemusular (5# 6ain 6al6ation (#C+A 5/
5$erussion : tym6ani 6erussion 6ain(#
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8tremity
• CR ? 3E
• Sianosis ;
• dema ;
• ,arn e8tremity /
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a0oratorium ( urinalisa#
+ i ik h il
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a0oratorium (urinalisa#
+enis pemeriksaan hasil
,arna Kunin) &eru!
Berat Fenis 1.474
$! >.4
Blood 3
eu&osit esterase ne)ati"
nitrit ne)ati"
$rotein 1
Biliru0in ne)ati" Aseton ne)ati"
Redu&si ne)ati"
Uronilino)en 1.4
eu&osit 75
ritrosit 157
6itel 1
Ba&teri 6ositi"
Silinder ne)ati"
Kristal ne)ati"
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BN 12.13.12
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Working diagnose
Primary : Suspect nephrolitiasis
Secondary : Urinary tract infection
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TREATMENT
Non-Medicamentosa:Non %os6italize
Diet : normal
Medicamentosa :
to"ade8 3 8 1 ta0letranitidin 381 ta0let
e-oo8ain 381
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$lannin)
• a0oratorium :
• BN
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3. 'r. A (74 years old#
• Mechanism of trauma : inFury aused 0ymotoryle aident t!e 6atient ras!edinto t!e 0a& o" a ar *!i! made a suddensto6 t!en !e "ell o !is motoryle and !isri)!t side o" t!e 0ody !it t!e side o" t!eroad and !it !is le"t le) on t!e ar andHnally endin) in a "ain)5do*n*ards6osition
• Injury organ : ri)!t s!oulder le"t "oot le"t
and ri)!t !and• Signs and symptoms : 6ain 0ruise on !is
le"t &nee and 0leedin) in !is lo*er li6.• Treatment pre hospital : -
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PRIMAR S!R"#
• Air*ay : $%#AR•
oo& : no o0strution• isten : no e8tra 0reat! sound• 9eel : t!ere *ere *arm air "rom 0ot! nose and mout!
• Breat!in) : $%#AR• Ins : !est *all mo-ement symmetrial RR 328/min
0ruise (5# !ematoma (;#• $al : -oal "remitus symmetrial• $er : sonor ri)!t < le"t• Aus : 0asi 0reat! sound -esiular r! 5/5 *! 5/5
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• Cirulation : No Sign &f Shock • ,arm e8tremities B$ : 174/144
•$ulse < 8/menit
• RR : 32 8
• em6 < 7=14C
• CR ?3@
•
Disa0ility• GCS 1 (2'>+#
6u6il iso!ori 7/7 mm entered
• Diret li)!t ree8/indiret li)!t ree8 /
•
86osure !ere *as no li"e t!reatenin) *ounds
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S#$&N'AR S!R"#
AMP%#
• Aller)y : 5
• 'ediation : 5• $ast Illness : 5
• ast 'eal : In t!e e-enin)
• -ent : 5
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(istory of illness
$atient male 74 years old ame to t!e RRSU UKI at 174 ,IB *it! om6lain o" inFurydue to a tra aident a0out an !our a)o
0e"ore !e ame to t!e !os6ital. ,itnessstated t!at 6atent !ad lost oniousness "or1 seonds 0ut a"ter t!at 6atient re)ainedoniousness 0y !imsel". $atien !ad inFury in
lo*er li6 t!e 7rd 2t! and t! Hn)ers on !isle"t !and and !is 2t! t! Hn)er on !is ri)!t!and le"t &nee. Nausea (5# +omittin) (5#
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(#A' T& T
(ead : Normoe6!aly
#yes : $u6il irular iso!ori7mm/7mm entered Diret i)!t Ree8
/ Indiret i)!t Ree8 / CA 5/5#ar : Normal Blood (5#Neck : Bruise (5# %ematoma (5#
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Thora) :5 Ins6etion: 0ruise (5# mo-ement o" !est
*all symmetrial
5 $al6ation : +oal "remitus symmetrial
5 $erussion : sonor ri)!t
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A*domen :
5Ins6etion : at
5Ausultation : 0o*el sound (# 28/min
5$al6ation : tenderness (5# de"ensemusular (5# 6ain 6al6ation (5#
5$erussion : tym6ani 6erussion 6ain(5#
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oalis status
• i6
• o*er li6 : o6en *ound
• %and :
•
Ri)!t !and : di)iti 2t! and t! • e"t !and : di)iti 7rd 2t! and t!
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Working diagnose
Vulnus Laceratum regio laia oris
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TREATMENT
Non-Medicamentosa:Non %os6italize
Diet : normal
Medicamentosa :
5 Neuro0ion 1 am65R / > Fam
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$lannin)
!ser"ation for # hours$ doing a
physical e%amination on the patiente"ery hour
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7. 's. N (1 years old#
• Mechanism of trauma : motoryle inFurys!e *as ridin) motor0i&e *it!out !elmet*!ile !er "rineds *as dri-in) and s!e "eltloss 0alane o" t!e motor0i&e t!at s!e "elt!ard ausin) !er to !a-e moderate !eadinFury and !er oniousness
• Injury organ : le"t &la-i&ula o6en *ound on!er sal6
• Signs and symptoms : 6ain
• Treatment pre hospital : *ound dressin)on t!e le"t !and usin) ransel -er0and onri)!t s!oulder
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PRIMAR S!R"#
• Air*ay : $%#AR•
oo& : no o0strution• isten : no e8tra 0reat! sound• 9eel : t!ere *ere *arm air "rom 0ot! nose and mout!
• Breat!in) : $%#AR• Ins : !est *all mo-ement symmetrial RR 348/min
0ruise (5# !ematoma (;#• $al : -oal "remitus symmetrial• $er : sonor ri)!t < le"t• Aus : 0asi 0reat! sound -esiular r! 5/5 *! 5/5
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• Cirulation :• ,arm e8tremities B$ : 124/L4
•
$ulse < >4 8/menit• RR : 34 8
• em6 < 7> 4C
• CR ?3@
•
Disa0ility• GCS 13 (7+3'2#
6u6il iso!ori 7/7 mm entered
• Diret li)!t ree8/indiret / li)!t ree8 /
•
86osure !ere *as an o6ened *ound on t!e sal6 o" t!e 6atient
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S#$&N'AR S!R"#
AMP%#
• Aller)y : 5
• 'ediation : 5• $ast Illness : 5
• ast 'eal : 5
•-ent : 5
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(istory of illness
$atient "emale 1 years old ame to t!e Ro" RSU UKI at 37.74 ,IB a"ter a traaident *it! loss o" oniousness ontinous
0leedin) "rom !er ear and "rom an o6ened*ound on !er !ead. S!e only o6ens !er eyesin res6onse to 6ain (3# %er 0est -er0alres6onse is inom6re!ensa0le sounds (+3#
!er 0est motori& res6ose is t!at s!e mo-esto*ards loalized 6ain as i" 0lo&in) t!e 6ain('2#.
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(#A' T& T
(ead : Normoe6!aly
#yes : $u6il irular iso!ori7mm/7mm entered Diret i)!t Ree8
/ Indiret i)!t Ree8 / CA 5/5#ar : Normal Blood (5#Neck : Bruise (5# %ematoma (5#
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Thora) :
5 Ins6etion : 0ruise (5# mo-ement o" !est*all symmetrial
5 $al6ation : re6itation in la-iula sinistra +oal "remitus symmetrial
5 $erussion : sonor ri)!t
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A*domen :
5Ins6etion : at
5Ausultation : 0o*el sound (# 28/min
5$al6ation : tenderness (5# de"ensemusular (5# 6ain 6al6ation (5#C+A 5/5
5$erussion : tym6ani 6erussion 6ain(5#
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a0oratorium
+enis pemeriksaan hasil
%0 111 )/dl
%t 77 M
!rom0osit 32 r0/u
eu&osite 3=244
KI'IA KINIK
Gula dara! se*a&tu 11 m)/d
C San
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C San
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Working diagnose
Primary : &rritati"e VP shunt tract
Secondary : contusio cereri$ edema cereri$ epiduralhematome
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TREATMENT
Non-Medicamentosa:
%os6italize
Diet : normal
Medicamentosa :
$eftria)one , ) gRanitidin , ) ta*
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$lannin)
• a0oratorium :
• Dara! en)&a6
• C Brain
• Ront)en "oto er-ial• 0ser-ation e-ery 1 minutes
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2. 'r. Ad (4 years old#
• Mechanism of trauma : !e 6atientuses +$ s!unt to
• Injury organ : ri)!t s!oulder le"t "oot
and le"t !and• Signs and symptoms : 6ain
• Treatment pre hospital : *ounddressin) on t!e le"t !and usin) ransel-er0and on ri)!t s!oulder
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S#$&N'AR S!R"#
AMP%#
• Aller)y : 5
• 'ediation : 5• $ast Illness : 5
• ast 'eal : 5
•
-ent : 5
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(istory of illness
$atient arri-es at t!e !os6ital om6lainin)a0out !o* "rom t!e ri)!t side o" !is !ead to!is ne& a +$ s!unt tu0e is -isi0le 0eause itis im6rinted on !is s&in. It is also red ands*ollen in t!e +$ s!unt im6rint on t!e ne&sine 1 *ee& a)o. !e 6atient also om6lainst!at !e o"ten "eels !eada!es sometimes.
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(#A' T& T
(ead : Normoe6!aly
#yes : $u6il irular iso!ori7mm/7mm entered Diret i)!t Ree8
/ Indiret i)!t Ree8 / CA 5/5#ar : Normal Blood (5#Neck : Bruise (5# %ematoma (5# S*ollen
( (in *!ere t!e -6 s!unt is im6rinted#
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Thora) :5 Ins6etion: 0ruise (5# mo-ement o" !est*all symmetrial
5 $al6ation : +oal "remitus symmetrial
5 $erussion : sonor ri)!t
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A*domen :
5Ins6etion : at
5Ausultation : 0o*el sound (# 28/min
5$al6ation : tenderness (5# de"ensemusular (5# 6ain 6al6ation (5#C+A 5/5
5$erussion : tym6ani 6erussion 6ain(5#
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Working diagnose
Primary : &rritati"e VP shunt tract
Secondary : contusio cereri$ edema cereri$ epiduralhematome
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TREATMENT
Non-Medicamentosa:
%os6italize
Diet : normal
Medicamentosa :
$eftria)one , ) gRanitidin , ) ta*
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$lannin)
• a0oratorium :
• Dara! en)&a6
• C Brain
• Ront)en "oto er-ial• 0ser-ation e-ery 1 minutes
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. 'r. S ( years old#
• Mechanism of trauma : 5
• Injury organ : ri)!t srotum
• Signs and symptoms : 6ain
• Treatment pre hospital-
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PRIMAR S!R"#
• Air*ay : $%#AR•
oo& : no o0strution• isten : no e8tra 0reat! sound• 9eel : t!ere *ere *arm air "rom 0ot! nose and mout!
• Breat!in) : $%#AR• Ins : !est *all mo-ement symmetrial RR 348/min
0ruise (5# !ematoma (;#• $al : -oal "remitus symmetrial• $er : sonor ri)!t < le"t• Aus : 0asi 0reat! sound -esiular r! 5/5 *! 5/5
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• Cirulation : no si)n o" shock• ,arm e8tremities B$ : 134/4
•
$ulse < 4 8/menit• RR : 34 8
• em6 < 7> 4C
• CR ?3@
•
Disa0ility• GCS 1 (2+'>#
6u6il iso!ori 7/7 mm entered
• Diret li)!t ree8/indiret / li)!t ree8 /
•
86osure !ere *as an o6ened *ound on t!e sal6 o" t!e 6atient
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S#$&N'AR S!R"#
AMP%#
• Aller)y : 5
•'ediation : 5
• $ast Illness : 5
• ast 'eal : 5
•
-ent : 5
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(istory of illness
$atient male 34 years old ame to t!e R o"RSU UKI at 37.74 ,IB *it! om6laint 6ain in!is srotum. %e "eel li&e t!is sine 7 !oursa)o. $ain t!at !e "elt ontinously andsometimes it ma&es !im nausea until !e )ot-omitted. Ri)!t 0e"ore !e suered "rom !is6ro0lem !e s!outed aloud many times.
$atient !ad 0een 0e"ore in years a)o and !e)ot o6erated. %e an urinate and de"eatednormally
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(#A' T& T
(ead : Normoe6!aly
#yes : $u6il irular iso!ori7mm/7mm entered Diret i)!t Ree8
/ Indiret i)!t Ree8 / CA 5/5#ar : Normal Blood (5#Neck : Bruise (5# %ematoma (5#
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Thora) :
5 Ins6etion: 0ruise (5# mo-ement o" !est*all symmetrial
5 $al6ation : +oal "remitus symmetrial
5 $erussion : sonor ri)!t
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A*domen :
5Ins6etion : at
5Ausultation : 0o*el sound (# 28/min
5$al6ation : tenderness (5# de"ensemusular (5# 6ain 6al6ation (5#C+A 5/5
5$erussion : tym6ani 6erussion 6ain(5#
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Genitalia
• 6enis :
• U : entral dis!ar)e5 Hstel 5
• Srotum :
•
Ri)!t srotum : mass a0normally !ard 6ressure 6ain immo0ilized
• e"t srotum : mass 5 tenderness 6ressure 6ain 5mo0ilized
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Working diagnose
Primary : 'ernia &nguinalis
Secondary : (
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TREATMENT
Non-Medicamentosa:
%os6italize
Diet : normal
Medicamentosa :
kaltrofen supp
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$lannin)
• a0oratorium :
• Dara! en)&a6
• USG
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>. 'rs. (1 years old#
• Mechanism of trauma : motoryleinFury
• Injury organ : ri)!t s!oulder le"t "oot
and le"t !and• Signs and symptoms : 6ain
• Treatment pre hospital : *ounddressin) on t!e le"t !and usin) ransel
-er0and on ri)!t s!oulder
PRIMAR S!R"#
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PRIMAR S!R"#
• Air*ay : $%#AR• oo& : no o0strution• isten : no e8tra 0reat! sound• 9eel : t!ere *ere *arm air "rom 0ot! nose and mout!
• Breat!in) : $%#AR• Ins : !est *all mo-ement symmetrial RR 348/min
0ruise (5# !ematoma (;#• $al : -oal "remitus symmetrial• $er : sonor ri)!t < le"t• Aus : 0asi 0reat! sound -esiular r! 5/5 *! 5/5
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• Cirulation : no sign of shock• ,arm e8tremities
•
Blood 6ressure : 134/4mm%)• $ulse < 8/menit
• RR : 33 8
• em6 < 7> 4C
• CR ?3@
• Disa0ility• GCS 1 (2+'>#
6u6il iso!ori 7/7 mm entered
• Diret li)!t ree8/indiret / li)!t ree8 /
• 86osure !ere *as an o6ened *ound on t!e sal6 o" t!e 6atient
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S#$&N'AR S!R"#
AMP%#
• Aller)y : 5
•
'ediation : 5• $ast Illness : 5
• ast 'eal : 5
•
-ent : 5
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(istory of illness
$atient "emale 1 years old ame to t!e Ro" RSU UKI at 37.74 ,IB a"ter a traaident *it! loss o" oniousness ontinous0leedin) "rom !er ear and "rom an o6ened*ound on !er !ead. S!e only o6ens !er eyesin res6onse to 6ain (3# %er 0est -er0alres6onse is inom6re!ensa0le sounds (+3#
!er 0est motori& res6ose is t!at s!e mo-esto*ards loalized 6ain as i" 0lo&in) t!e 6ain('2#.
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(#A' T& T
(ead : Normoe6!aly
#yes : $u6il irular iso!ori7mm/7mm entered Diret i)!t Ree8
/ Indiret i)!t Ree8 / CA 5/5#ar : Normal Blood (5#Neck : Bruise (5# %ematoma (5#
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Thora) :
5 Ins6etion: 0ruise (5# mo-ement o" !est*all symmetrial
5 $al6ation : +oal "remitus symmetrial
5 $erussion : sonor ri)!t
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A*domen :
5Ins6etion : at
5Ausultation : 0o*el sound (# 28/min
5$al6ation : tenderness (5# de"ensemusular (5# 6ain 6al6ation (5#C+A 5/5
5$erussion : tym6ani 6erussion 6ain
(5#
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a0oratorium ( dara! #
+enis pemeriksaan hasil
%0 111 )/dl
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a0oratorium (urinalisa#)
%t 77 M
!rom0osit 32 r0/u
eu&osite 3=244
KI'IA KINIK
Gula dara! se*a&tu 11 m)/d
W ki di
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Working diagnose
Primary : Moderate 'ead &n)ury
Secondary :
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TREATMENT
Non-Medicamentosa:
%os6italize
Diet : normal
Medicamentosa :•
$eftria)one inj• Ranitidine inj
• .etorolac Inj
• Manitol
• Plasmine)
• "it . Inj
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$lannin)
• a0oratorium :
• Dara! en)&a6
• C Brain
•Ront)en "oto er-ial
= 's + (34 years#
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=. 's. + (34 years#
•Mechanism of trauma: motoryleinFury
• Injury organ : -
• Signs and symptoms : 6ain
• Treatment pre hospital : -
PRIMAR S!R"#
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PRIMAR S!R"#
• Air*ay : $%#AR• oo& : no o0strution• isten : no e8tra 0reat! sound• 9eel : t!ere *ere *arm air "rom 0ot! nose and mout!
• Breat!in) : $%#AR• Ins : !est *all mo-ement symmetrial RR 348/min
0ruise (5# !ematoma (;#
• $al : -oal "remitus symmetrial• $er : sonor ri)!t < le"t• Aus : 0asi 0reat! sound -esiular r! 5/5 *! 5/5
Ci l ti i f h k
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• Cirulation : no sign of shock
• ,arm e8tremities
•
Blood 6ressure : 174/144mm%)• $ulse < 4 8/menit
• RR : 34 8
• em6 < 7> 4C
• CR ?3@• Disa0ility
• GCS 1 (2+'>#6u6il iso!ori 7/7 mm entered
• Diret li)!t ree8/indiret / li)!t ree8 /
• 86osure
!ere *as no o6ened *ound at t!e e8tremity
S#$&N'AR S!R"#
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S#$&N'AR S!R"#
AMP%#
• Aller)y : 5
•
'ediation : 5• $ast Illness : 5
• ast 'eal : 5
•
-ent : 5
(istor of illness
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(istory of illness
$atient "emale 34 years old ame to t!e Ro" RSU UKI. T!e 6atient *as in a motoryleaident sine t!en !e !as 0een !a-in)!eada!es and !as 0een "eelin) Os6inny@.
S!e *as !ysterial *!en s!e arri-ed at t!e!os6ital 0eause s!e *as *orried a0out !er"riend *!o *as also in t!e aident and inritial ondition. A"ter 3 !ours o" o0ser-in)
t!is 6atient s!e is alm !er -ital si)ns are0a& to normal (134/4 *!ile on arri-al !er0lood 6ressure *as 174/144#
(#A' T& T
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(#A' T& T
(ead : Normoe6!aly
#yes : $u6il irular iso!ori7mm/7mm entered Diret i)!t Ree8
/ Indiret i)!t Ree8 / CA 5/5#ar : Normal Blood (5#Neck : Bruise (5# %ematoma (5#
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Thora) :
5 Ins6etion: 0ruise (5# mo-ement o" !est*all symmetrial
5 $al6ation : +oal "remitus symmetrial
5 $erussion : sonor ri)!t
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A*domen :5Ins6etion : at
5Ausultation : 0o*el sound (# 28/min
5$al6ation : tenderness (5# de"ensemusular (5# 6ain 6al6ation (5#C+A 5/5
5$erussion : tym6ani 6erussion 6ain
(5#
Working diagnose
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Working diagnose
Primary : Multiple e%coriation
Secondary :
TREATMENT
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TREATMENT
Non-Medicamentosa:
0ser-ation + "or !our
Medicamentosa :• Ranitidine ,)g
• Tofede) ,)g
! &
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!an& you