Emergency Unit

Night Shift Report

December 16th 2014
Assistant: dr. Hendy/dr. Benny
Co-assistant:
Dian Nur Martika A
Glen Jacobs S
Leonard Evan M
Kharisma Pertiwi
Riya Hanaza R
Nadia Latifa D
Dyah Anjani K.S

Trauma: 1

Hospitalize: 3

Non-Trauma: 2

Non-Hospitalize: -

1. Ms. W (73 years old)

Main complaint : bleeding from
mammae dextra
Secondary complaint : Pre hospital treatment : tampon on
dextra mammae, analgetic, vit K

History of illness
Patient came to ERS RSU UKI with main complaint
bleeding from mammae dextra 3 days ago. Bleeding a
lot continously. In Sept 2014 patient went to
RS.Dharmais to consultation about mass in breast.
Diagnose from RS. Darmais was mammae cancer but
she and her family denied to get chemotherapy. She has
been got some medication like analgetic, vit K, and
tampon on dextra mammae.

Vital Sign

General conditions : look severe sick

consciousness: GCS E3 V2 M5
BP : 110/70mmHg
Pulse: 84x/menit
RR: 22 x/menit
temperature : 36,4 oC

HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm, centered,
Direct Light Reflex +/+, Indirect Light Reflex
+/+, CA -/Ear : Normal, LCS (-), Blood (-)
Neck : Bruise (-), Hematoma (-)

Thorax :
- Inspection

: bruise (-), movement of chest wall

symmetrical
- Palpation
:- Percussion : - Auscultation : basic breath sound vesicular
left, wh-/-, rh-/-.

Abdomen :
- Inspection
- Auscultation
- Palpation
- Percussion

: flat, bulging (-)

: bowel sound (+) 8x/min
: tenderness (-), defense muscular
(-), pain palpitation (-)
: tympani, percussion pain (-)

Extremities
CRT <2, warm, sensoric (+)

Locale status
mammae :
I :mass diameter : 13cm Thick : 5 cm,
ulcus +, pus +, active bleeding
Pal : Per : A: basic breath sound vesicular
left, wh-/-, rh-/-.

Laboratorium 16/12/14

Working diagnose
Ca Mammae dextra T4bNXM1
Anemia
Hiponatremia
Hipoklorinemia
hipoalbuminemia

TREATMENT
Non-Medicamentosa:
Hospitalize
Diet : high protein high karbohidrat
NGT
IVFD : I Nacl 3%, II futrolit, I RL(24 hours)
PRC 300cc
Hb: 9 g/dl

Medicamentosa :
Levofloxacin1x500mg (IV)
Paracetamol
Ca Gluconas 1 amp (IV)
Vit K 1 amp (IV)
Plasminex 2X1 amp (IV)

2. Mr. O (43 years old)

Main complaint : pain in his genitalia
Secondary complaint : -

History of illness
Patient came to ERS RSU UKI with main complaint
pain in his scrotum since 2 weeks ago. The pain can be
felt when patient on sit position and the scrotum was
touched. Patient didnt know caused from his complaint,
only the pain came suddenly. The pain isnt continously
sometimes come and then not pain anymore. The pain
had not been cured before. Patient didnt have complaint
like this before and never used some drugs to reduced
his complaint.
Family history : Diabetic Melitus

Vital Sign

General conditions : Look mild sick

Consciousness: E4V5M6
BP : 120/90mmHg
Pulse: 102x/minute
RR: 22 x/minute
Temperature : 36,3 oC

HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm, centered,
Direct Light Reflex +/+, Indirect Light Reflex
+/+, CA -/Ear : Normal, LCS (-), Blood (-)
Neck : Bruise (-), Hematoma (-)

Thorax :
- Inspection

: bruise (-), movement of chest wall

symmetrical
- Palpation
: Vocal fremitus symmetrical
- Percussion : sonor right=left, percussion pain (-)
- Auscultation : basic breath sound vesicular
right=left, wh-/-, rh-/-.

Abdomen :
- Inspection
- Auscultation
- Palpation
- Percussion

: flat, bulging (-)

: bowel sound (+) 7x/min
: tenderness (-), defense muscular
(-), pain palpitation (-)
: tympani, percussion pain (-)

Extremities
CRT< 2, warm, sensoric (+)

Locale status
Genitalia externa
Penis :
OUE : secret -, stricture -,
circumcision-, pain-,
Scrotum :
I : swelling (+) hyperemis (+), pus (+)
Palpation : pain (+), dextra testis not
palpable,

Laboratorium

Na : 130 mmol/L
K : 4,1 mmol/L
Cl : 96 mmol/L
Hb : 11,6 gr/dl
L : 11.700/ul
Ht : 32,3 %
T : 347.000/ul
GDS : 453mg/dl

Urinalisa
Reduction +3
Leucocyt 4-6/LPB

Working diagnose
Abses Regio
scrotalis
DM type 2
Hiponatremia
Anemia

Treatment

Planning

Diet : biasa
IVFD

Kompres luka
dengan Nacl

I RL

Medikamentosa
Ceftriaxone 1 gr
(IV)
Tofadex 3 X 1
amp (IV)
Ranitidine 2 X 1
amp (IV)

TN. A ( 54th)
Mechanism of the Trauma
Patient fell from motorcycle due to abrupt stop because
the car in front of him sudden break. Patient fell left
sided so the bike he ride fall on him.

Injury of target organ

Extremities
Symptoms and signs
Pain, wound, edema
Treatment Pre Hospital (-)

PRIMARY SURVEY
Airway : CLEAR
Look
Listen
Feel

: no obstruction
: no extra breath sound (gurgling (-), snoring (-),
stridor (-))
: there were warm air from both nose and mouth

Breathing : CLEAR
Inspection: bruise (-), chest wall movement
symmetrical, RR 18 x/min, hematoma ()
Pal
: crepitation (-)
Per
: sonor right = left
Aus
: basic breath sound bronchial, rh -/-, wh -/-

 Circulation : No Sign Of Shock

Warm extremities
Blood pressure 120/80 mmHg
Pulse = 108 x/minute
Temp =36 0C
CRT <2

Disability
GCS 15 (E4M6V5) isochoric pupil 3/3 mm, centered,
Direct light reflex/indirect light reflex +/+

Exposure
There was no life threatening wounds

SECONDARY SURVEY

AMPLE
Allergy
Medication
Past Illness
Last Meal
Event

:::: in the evening

: Accident

HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,
centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA -/Ear : Normal, LCS (-), blood (-)
Neck : Bruise (-), hematoma (-)

Thorax :
- Inspection

: bruise (-), movement of chest wall

symmetrical
- Palpation : crepitation (-), palpation pain (-)
- Percussion : sonor right = left, percussion pain
(-)
- Auscultation: vesicular basic breathe sound
right=left, wh-/-, rh-/-.

 Abdomen
- Inspection
- Auscultation
- Palpation
- Percussion

: flat, bruise (-),

: bowel sound (+) 6x/min
: tenderness (-),muscular
defense (-)
: tympani, percussion
pain (-)

Locale status
L : multiple lesion, swollen,
F : crepitate, pain
M : he cant lift his left leg, finger
movement (+)
CRT< 2, warm, sensoric (+)

History of illness
Patient brought to hospitals emergency unit
because a motorcycle accident about an hour
before arrive at hospital. He got scratches on his
left and right palm, and his left and right lower
leg. He also have difficulty to move his leg. There
is an open wound on his right fourth finger and
left knee. He didnt have any complain for
dizziness, feeling sick or vomiting.

Lab

Hemoglobin
Leukocyte
Hematocrite
Trombocyte

13.4 g/dl
15.200 /uL
40,1 %
269.000 /uL

X-RAY

Working diagnosis
Close fracture intraarticular os tibia sinistra
without NVD
Multiple vulnus excoriasi
Multiple vulnus laceration

TREATMENT
Non Medicamentosa :
- Hospitalized pro ORIF
- Wound toilet
- Diet : Biasa
- IVFD : I RL + III amp Ketorolac
Medicamentosa :
- Ceftriaxone 2x1 gram
- ranitidin 2x1