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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!



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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'>+#


• 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


• 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



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A*domen :

5Ins6etion : at


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


• 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"#





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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#


• 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


• 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



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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


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A*domen :

5Ins6etion : at


5$al6ation : tenderness (5# de"ensemusular (5# 6ain 6al6ation (5#C+A 5/5


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a0oratorium


%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


• 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


/ 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



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A*domen :

5Ins6etion : at




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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


• Treatment pre hospital-

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PRIMAR S!R"#





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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+'>#



•

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



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Thora) :

5 Ins6etion: 0ruise (5# mo-ement o" !est*all symmetrial



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A*domen :

5Ins6etion : at




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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!



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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+'>#



• 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



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Thora) :




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A*domen :

5Ins6etion : at



5$erussion : tym6ani 6erussion 6ain

(5#

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a0oratorium ( dara! #


%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 : -


• 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!


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


• 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



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Thora) :




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A*domen :5Ins6etion : at



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

morpot 15 des 2014

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