Morning Report 28 November - Copy - Copy

7/23/2019 Morning Report 28 November - Copy - Copy

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MORNING REPORTDEPARTMENT OF

SURGERYBy: B22



Identity

• Name : Tn. S

• Age : 44 yo

• O!"ation : #a$me$

• Add$e%% : &$ondong 'amongan• Date : No(em&e$) 2*t+ 2,-

• No RM : ,/.0/.10



Anamnesis

Chief Complaint: "ain in +ead in!$ie% a#te$ #a''ing #$om a moto$

y'e

MOI: "atient $e#e$$a'% #$om P3U &'im&ing it+ Se(e$e &$ain in!$y.

T+e "atient om"'ained o# "ain in t+e +ead o!nd a#te$ an

aident %ie at ,*.,, PM. Patient #e'' #$om a moto$y'e d!$ing ao''i%ion it+ anot+e$ moto$y'e in #$ont o# +im &ea!%e t+ey do

not t!$n on t+e 'ig+t%. T+en t+e "atient !non%io!% and +ad

(omited 2 time% a""$o5iate'y - !" medi!m. 6ontaining #ood.

Patient a'%o did not ea$ a +e'met. 7eada+e 89) PTA 8;

Past Illness History : DM and 7T 8;

Family Illness History : DM and 7T 8;

Social Illness History: ;



<ita' Sign

•BP : /4=> mm7g

•PR : /-5=mnt

•

t : 0>.2,

6•RR : -1 5=mnt



P$ima$y S!$(ey

A: 6'ea$) ga$g'ing 8;) %no$ing 8;) %"ea? @!ent'y 89)"otentia' o&%t$!tion 8;

B: %"ontan) RR -15=mnt) (e%=(e%) R+ ;=;) + ;=; SaO2-,, it+ O2 %!""o$t NRM -, '"m

6: A$a' DR) 6RT C2) N /-5=mnt $eg!'a$) BP /4=/mm7g

D: G6S 0>) 'ate$a'i%ation 8;) PBI 0mm=0mm

E: tem" 0>)2 O6) (!'n!% a"" et $egio %!"$a o$&ita

de5t$a "anang m +eating) +ematome "a'"e$&$aD et S) (!'n!% a""e$te!m na%a' 25- m) ?$e"ita%ina%a' 89) e"ita5i% 89 edema ma5i'a D et S) @oatingma5i'a 89) #a'% mo(ement 89



Seonda$y S!$(ey

G6S: 0>.

3=: a;=i;=;=d;) 3GB 8;) in$ea%ed o# <P 8;

T+o: %ymmet$ia' ) $et ;=;

P: (e% =(e%) $+ ;=;) + ;=;6: S-S2 t!ngga') m!$m!$ 8;) ga''o" 8;

A&d: de#an% m!%!'a$ 8;) met 8;) BU9N) tende$ne% 8;

E5t: aie ;) a$a' DR



6'inia' "+oto



6'!e and 6!e

ma'e) 44 yo

G6S 0>

(!'n!% a"" et $egio %!"$a o$&ita de5t$a "anang m

+eating) +ematome "a'"e$&$a D et S) (!'n!%a""e$te!m na%a' 25- m) ?$e"ita%i na%a' 89) e"ita5i%89 edema ma5i'a D et S) @oating ma5i'a 89) #a'%mo(ement 89

(omiting



6'inia' A%%e%ment

Mi'd &$ain in!$y

F$at!$e ma5i'a

F$at!$e na%a'



PANING DIAGNOSIS

• T+o$a5 5;$ay

• 6T S6AN

• D



a&o$ato$i!m

Hematologi

•7emato?$it : 4./8 4,;4) P 0;4*

•7emog'o&in : -0., mg=d' 8P-2;-> mg=d')

-0;-1 mg=d'

•e!?o%it : -2.2 = ! 84,,,;--.,,,

•

T$om&o%it : -*> =! 8-,.,,,;4,.,,,•Ne!t$o"i' : **.0 8 4/.,;>*.,

•im#o%it : -.- 82.,;00.,

•Mono%it : .- 80.,;*.,

•

Eo%ino' : ,.0 8-.,;2.,•Ba%o' : 2.2 8,.,;-.,

•E$it$o%it : 0.10 = !80.1,,.,,,;.0,,.,,,

•MP< : 4 @ 8;-,

•M6< : 1.-, @ 81*.,,;-,,.,,,

•M67 : 2*.* "g 821.,,;0>.,,

•M676 : 02.>, g=d80-.,,;0*.,,

•

RD : -2 8-,;->.•GDA : -2,

•7&%AG negati#



P'anning T+e$a"y

O2 NRM -, '"m

In#. oading a%e$ing -,,, maintenene-,,=24am

In. MatamiHo'e 05- g$ i(In. Panto"$aHo'e 254,mg i(

In. 6e#t$ia5on 25- g$ i(

In. Pi$aetam 450 g$ i(

in. A%am t$a?ne%amat 05,, mg i(

6on%!'t S".B3



Monito$ing

6om"'aint

<ita' %ign



Ed!ation

• E5"'aine to t+e #ami'y a&o!t t+e di%ea%e) a&o!t it%t+e$a"y and inte$(ention i'' &e done) and a'%o a&o!tom"'iation and "$ogno%i%.

Morning Report 28 November - Copy - Copy

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