Emergency Room

Morning Report
june, 16th 2012
1 trauma and 2 non trauma

1. Mr. F (24 YO)

Chief complaint abdomen Additional complaint bigger than usual : pain in his lower
:size of his scrotum was

 History of illness : ( Autoanamnesis )

3 hours before admittance, patient suddenly felt pain in his lower abdominal , the pain is intermitten and felt like crushed, Patient also complained his scrotum got bigger than usual but cant be repositioned into the right place. Nausea (+), vomitus (+) 1x, vomit of the last food eaten. Patient can defecate and gas normally. Patient had never been treated. Patient had the same problem since 2005, but bigger scrotum didnt happen everyday. his scrotum got bigger while hes doing a heavy job. But he can replaced the scrotum to the normal place by lift up his two legs or used his hands to reposition.

General Examination BP : 120/90mmHg HR : 60x/m RR : 16x/m T : 36.5C Head : Bruise (-), hematom (-), tumor (-), blood (-) Eyes : Pupil round, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex+/+

Neck Thorax

: Bruise (-), hematom (-), no nn.ll enlargement palpable

Insp : movement of chest wall symmetrical Pal : VF right=left Per : sonor right = left Aus : Basic breath sound vesicular, wh -/-, rh-/-

Abdomen Ins : flat, hematom (-), bruise (-), defence muscular (-) Pal : smooth, H/L not palpable enlarged Per : Percusion tenderness (-), Tympani Aus : bowel sound (+) 2x/m
Extremity cap. refill < 2, warm extremities, edema (-),

Localized status
Regio scrotalis insp: bigger scrotum , size 10x12 cm, transilumination (-), hematome (-) pal : upper border unclear Aus : bowel sound 1x/min

 Rectal toucher
Insp : skin tag (-), mass (-) Pal : TSA : squeezing Mucose : smooth Ampule recti no colapse Tenderness (-) Prostate Upper pool palpable Sulc medianus : palpable Latero lateral : 2 cm Nodul (-) Handscoen : Blood (-) Feaces (-)

Regio penis Ins : Oue in the middle, circumsicion (+), pus (-), blood (-) Pal : fibrosis (-), tenderness (-)

Thorax X-ray

DIAGNOSIS
Hernia scrotalis dextra stadium irreponible inkarserata

TREATMENT
Pro herniotomy Catheter initial urine : 100cc NGT flowed Diet : puasa IVFD : II RL/24 jam MM : terfacef 2x 1 g Ranitidin 2 x 1 ampul Ondancentron k/p muntah 1 amp Ketesse 3 x 1 amp

An. N (5 years old)

PRIMARY SURVEY
Self protection (gloves) injury on her left leg due to scratch by the sharp side of iron drum ,

Airway : Clear Breathing :

Insp : RR: 30x/m, movement of chest wall symmetrical, bruise (-) Pal : VF R=L Per : sonor right = left, percussion pain (-) Aus : Basic breath sound vesiculer

 Circulation
warm extremities, Pulse = 90 x/min , BP = 110/70 mmHg, Temp = 36,5c, capillary refill < 2

Disability
GCS 15 E4V5M6, pupil isochoric 3 mm / 3 mm, direct light reflex/indirect light reflex +/+, lateralization (-)

Exposure
Theres no life threatening wound

Secondary survey
Chief complain: She has wound at her left leg Secondary complain: -

History of illness (Anamnesis)

1 hours before admittance, Her parents told she was biking and arrived at home with wound in her left leg, she was scratched by the sharp side of the iron drum. According to the patient, she didnt fall off the bike.

AMPLE
Allergy Medication Past Illness Last Meal Event :::: 3 hours before admittance : scratch

Head : Bruise -, oedem -, Hematom -, tumor -, blood Ear : normal, LCS -, blood Neck : Bruise (-), hematom (-), no nn.ll enlargement palpable Thorax : Insp : movement of chest wall symmetrical, bruise (-) Pal : VF R=L Per : sonor right = left, Aus : Basic breath sound vesiculer, wh -/, rh-/-

Abdomen Ins : flat, hematom (-), bruise (-), defence muscular (-) Pal : tenderness (-) Per : Percusion tenderness (-), Tympani Aus : bowel sound + 4x/m Ekstremitas cap. refill < 2, edema (-), warm extremity,

Localized Status
regio cruris sinistra Look: vulnus scissum 5x1x1 cm active bleeding (+), hematome (-) Feel : tenderness(+), crepitation (-) Move: active & passive movement normal

Diagnosis
Vulnus Scissum regio cruris sinistra

Therapy
Wound toilet Hecting Vaccine TT Amoxicillin syrp 3 x II cth Paracetamol syrp 3 x II cth

1. Ms. I (14 YO)

Chief complaint Additional complaint : swallowed a needle : feel uncomfort in her right upper abdominal

 History of illness : ( Autoanamnesis )

Half hour before came, patient told that she was swallowing a needle. At first she feel uncomfort in her throat. Then she feel uncomfort in her stomach , in her right upper abdominal ,because a needle for a few second. She was brought by her family. Pain in abdominal (-) Dispnoe (-) Nausea (-), vomitus (-) Patient didnt take any action to reduce complaint.

General Examination BP : 110/70mmHg HR : 87x/m RR : 18x/m T : 36.5C Head : Bruise (-), hematom (-), tumor (-), blood (-) Eyes : Pupil round, isochoric 3mm/3mm, centered, Direct Light Reflex +/+, Indirect Light Reflex+/+

Orofaring Neck Thorax

: mucosa normal, edem (-), ulcer (-) , bleeding (-), corpus alienum (-), : swallow normal, Bruise (-), hematom (-), no nn.ll enlargement palpable

Insp : movement of chest wall symmetrical Pal : VF right=left Per : sonor right = left Aus : Basic breath sound vesicular, wh -/-, rh-/-

Abdomen Ins : flat, hematom (-), bruise (-), defence muscular (-) Pal : smooth, H/L not palpable enlarged Per : Percusion tenderness (-), Tympani Aus : bowel sound (+) 8x/m
Extremity cap. refill < 2, warm extremities, edema (-),

Diagnosa
Corpus alienum suspect in gaster

Therapy
Pro inpatient rejected MM:
sporetik 2x1 tab Ketesse 3x1 tab Omeprazole 1x1 tab

Advice:
high fiber diet Examine the stool quick come to hospital when feel nausea, pain in abdomen increase