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Traffic Accident Patient Report

1. A 23-year-old male patient presented to the emergency room with wounds covering his entire body after being involved in a traffic accident where he collided with a meatball cart. 2. On examination, he had second degree burns over 34% of his body as well as lacerations and abrasions. 3. The treatment plan included wound cleaning, IV fluid resuscitation, pain medications, antibiotic ointment, and monitoring urine output.

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Naeny Blegur
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39 views11 pages

Traffic Accident Patient Report

1. A 23-year-old male patient presented to the emergency room with wounds covering his entire body after being involved in a traffic accident where he collided with a meatball cart. 2. On examination, he had second degree burns over 34% of his body as well as lacerations and abrasions. 3. The treatment plan included wound cleaning, IV fluid resuscitation, pain medications, antibiotic ointment, and monitoring urine output.

Uploaded by

Naeny Blegur
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

MORNING REPORT

MEY 21TH 2018 (14.00-21.00) DM RIA,


KONSULEN DM ZUHAIFAH
DR. ALDERS NITBANI, SP.B
PATIENT I
Name : Mr. MT
Age : 23 yo
Gender : Male
Address : Bakunase
ANAMNESIS
Chief complaint: wounds on the whole body after traffic
accident
Present Complain :
The patient came to ER because he had wounds on the whole
body. 1 hour before, he has traffic accident when he wants to
go to the market. He said that he hit the cart seller of meatballs
and then he fell. His chest was hit the road, after that the cart
seller of meatballs fell and hit the patient. The meatball’s sauce
was spill on his whole body. Dizziness (-), vomiting (-), double
vision (-), blood out of ear (-) and nose (+).
PRIMARY SURVEY
A : Clear
B : RR : 28x/mnt, Chest expansion symetric
C : BP : 120/60mmHg, HR : 50x/mnt, regular
D : GCS E4 V5 M6
E : Combustio grade II B 34%
SECONDARY SURVEY
GCS : GCS E4 V5 M6, Time and people oriented good
 Head : lesion (+)
 Eye : Conjunctiva anemis -/-, pupil isocor RCL +/+,
 Ear : Otorrhea (-)
 Nose : epistaxis (+), rinorhea (-) lesion (+)
 Neck : Lymphadenopathy (-)
THORAX
lesion (+)
Lung
 Inspection : Chest expansion symetric,
 Palpation : Vocal fremitus (R=L), mass (-),
crepitation (-)
 Perkution : sonor (+/+)
 Auscultation : Vesiculer (+/+) , Ronchi (-/-), Wheezing
(-/-)
Heart:
 S1/S2 single, murmur (-), gallop (-)
ABDOMEN
 Abdomen
 Inspection : flat, lesion (+)
 Auskultation : peristaltic sound normal
 Palpation:
 distended (-) Defans Muscular (-) tenderness of
epigastrium (-)
 Percussion :
Tympani (+)
EXTREMITIES
 Upper Extremities
 Look : lesion (+) , deformity (-)
 Feel : warm, CRT <2 sec (+), A. Radialis pulse D/S (+/+)
Lower extremities
 Dextra :
 Look : lesion (+)
 Feel : warmer, CRT <2 sec (+)
 Sinistra :
 Look : lesion (+)
 Feel : warmer, CRT <2 sec (+), pulsation A. Dorsalis pedis (+)
LOCALIZED STATUS
a. Combustio grade II B 34%
ASSESMENT
Combustio grade II B 34%
PLANNING
- release patient clothes
-wound toilet using NaCl
-IVFD RL loading 1000 cc  2000cc/24hours
- Inj Ketorolac/8 hour
- drip novalgin
-salep antibiotic
- monitoring urine produce (

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