7/28/2019 15 february 2013.ppt

1/17

MORNING REPORT

SURGERY DEPARTMENT

DM E-1715th February 2013

7/28/2019 15 february 2013.ppt

2/17

Patients Identity

Name : Mr. S

Age : 55 year

Sex : man ID : 082597

Religion : moslem

Address : Lamongan

7/28/2019 15 february 2013.ppt

3/17

Summary of Database

Chief complaint : right ear pain

Present illness history:

Patient complained pain in right ear after got traffic accident. The

accident happened for about 15 minutes before hospitalized.

When the accident happened, patient was driving becak. A motor

driver crashing his becak suddenly from his behind side. Thenpatient fallen down to the right side of his body. He remembered

the accident exactly. He felt headache. Nausea (-). Vomit (-). His

right ear was bleeding.

7/28/2019 15 february 2013.ppt

4/17

Patients Status

Vital signs

General appearence, awareness,

GCS

Weak , CM, 456

Blood Pressure 141/97 mmHg

Pulse Rate 76x/mnt

Temperature 36,1 C

Respiratory Rate 20X/mnt

7/28/2019 15 february 2013.ppt

5/17

Primary Survey

Airway + control servical

- airway clear (+), snoring (-), gargling (-)

Breathing

- simetric (+), ves/ves, rh -/-, wh -/-, RR 20

x/minutes

Circulation

- acral: dry and warm to touch

- pulse rate: 76 x/m

- heart rate: 141/97 mmhg

7/28/2019 15 february 2013.ppt

6/17

Disability

- GCS 456

- light perception +/+- Pupil isocor 3mm/3mm

- lateralisation (-)

Exposure- temperature 36,1 C

- bloody otorea in auricularis dextra (+)

- bloody rhinorea (-), battle sign (-), racoon eyes(-)

7/28/2019 15 february 2013.ppt

7/17

Secondary survey

Head :

An -/- ; Ict -/- ; Cya -/- ; Dysp

Thorax

Symmetric -, retraction -

Pulmo : RR: 20x/m, Ves/ves, Rh-/-, Whz-/-

Cor : HR: 76x/m, reg (+) S1S2 tunggal, M-

7/28/2019 15 february 2013.ppt

8/17

Abdomen

Inspection : flat

Palpation : soefl, pain (-) in all quadranabdomen, H/L just palpable

Auscultation : Bowel sound (+) N

Percution : met (-)

Extremity : acral warm and dry

7/28/2019 15 february 2013.ppt

9/17

LABORATORY FINDING

Diffcount : 11/3/35/31/19

Hct : 38,8 %

Hb : 13.0 mg/dl

Leukosit : 7.100

Trombosit : 233.000

7/28/2019 15 february 2013.ppt

10/17

Clue and cue

Man , 55 years

Post traffic accident

PTA (-)

Headache Nausea (-)

Vomit (-)

Bloody otorea +/-

Battle sign -/-

Bloody rhinorea -/-

Racoon eyes -/-

7/28/2019 15 february 2013.ppt

11/17

Problem List

Post traffic accident

PTA (-)

Headache (+) Bloody otorea +/-

7/28/2019 15 february 2013.ppt

12/17

Initial Diagnose

Mild head injury

7/28/2019 15 february 2013.ppt

13/17

Planning of diagnose

CT Scan

7/28/2019 15 february 2013.ppt

14/17

7/28/2019 15 february 2013.ppt

15/17

Planning of therapy

O2 NC 3 lpm

IVFD Asering 1500 cc/ 24 hour

Inj. Ketorolac 3x30 mg

Inj. Ranitidin 2x50 mg

Inj. Piracetam 4x1 gr

Inj. Ceftriaxon 2x1 g

7/28/2019 15 february 2013.ppt

16/17

Monitoring

Vital signs

Patients complain

7/28/2019 15 february 2013.ppt

17/17

Prognosis

Dubia ad bonam