MORNING REPORTAPRIL 29TH 2013

Konsulen dr. Jean Pello, SpB

1St Case

BIODATA Name : MD Age : 4 years old Sex : Male Address : Sikumana

Anamnesis

Chief Complaint : Fell from the carMOIpatient come to ER because of falling from the parked car several minutes ago. The child cry a lot and blood was over the face. There’s a wound at the right forehead. The kid didn’t loss the consciusness, no nausea, no vomit, but there’s headache presents. There’s no other wound or other complaints.

Primary Survey A: Patent, clear B : RR: 24 times/min, spontan C : CRT : <2”, Pulse: 92 times/minute,

reguler. D : GCS E4V5M6 E : V. Laceration on region Frontal

dextra, 2cm

Secondary Survey GCS : E4 V5 M6 Head : Normal eyes : anemic (-/-), light reflex (+/+),

icteric (-/-) , isokhor +/+ Ear : normal Nose : normal Neck: Normal

Thorax Inspection : chest expansion simetrics,

reguler, abdominothoracal, Bruish (-) Palpation : vocal fremitus R=D, krepitasi

(-), Pain (-) Percusion: sonor (+/+) Auscultation : vesicular (+/+), ronchi

(-/-), wheezing (-/-)

Abdomen Inspection : look flat, follow the chest

expansion Palpation : pain (-), mass (-), tenderness

(-) Percusion : timpany (+) Auscultation : peristaltics (+), normal

Extremity

Look (normal)Feel normalpain (-)

Move ROM : normal

Assessment Vulnus laceratum at regio frontal dextra

Planning therapy Wound toilet and primary hecting Anti tetanus serum Paracetamol 250 mg 3x1 tab Amoxicillin 250 mg 3x1 tab

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Patient Identity Name : Mrs. WN Sex : Female Age : 51 y.o Religion : Catholic Job : Housewife Adress : Soe

History Chief complaint: shortness of breathe 2 days before

hospitalize MOI:

Shortness of breath has been felt for a long time, experienced again 2 days after patient received an introductory home from the hospital. Patients treated till date 21/03/14 04/26/14 26 with a diagnosis of ca. mammary sinistsra. Ca experienced since 2009, breast surgery. In 2012 appeared the bump, bump in 2013 turned into a wound. August 2013 appear small bumps around the left breast to the right spread to the neck and armpits. The bumps on the left side neck pain when touched. Because it is often shortness of breath, in 2014 the patient had 6 times the puncture lung fluid, four times in the left lung and right lung 2 times. Bumps that have become wound was cut then sent for examination, then the result is 2 weeks out. 2 months ago while being treated, the patient's legs and hands swelled. History urinating blood while being treated. unconsciousness (-), nausea (+), vomit (-), dizziness (-).

Habit history: smoke five to six cigarettes / day since the age of 21 years and drank alcohol

Primary Survey Airway: clear Breathing: 36 x/min• Circulation:

Pulse: 97x/min Disability: E4V5M6 Exposure : covered with gauze

Secondary Survey GCS E4V5M6 Head: simetric, normocephal Eye : anemic (-/-), light reflex (+/+), icteric

(-/-), isokor (+/+) Ear : Normal Nose : Normal Mouth : Normal Neck: enlarged lymph nodes (+), multiple,

cervical region, axilla region, chest region. Size: 1cm, elastic, immobile, tenderness (+)

Throat : Normal

Thorax Inspection : chest expansion simetrics, reguler, Palpation : edema (-), crepitation (-), tenderness (-) Percusion : sonor (+/+) Auscultation : vesicular (+/+), ronchi (+/+), wheezing(-/-)

Abdomen Inspection : flat, mass (-), wound (-) Auscultation : peristaltics (N) Palpation : tenderness pain (-) Percussion : timpanic sound (+)

Extremity Look

Deformitas (-), shortening (-), lengthening (-), swelling (+)

Feel CRT <2’, warm, pulsation of a. Dorsalis pedis

sinistra and dextra (+), Sensoris (+), crepitation (-)

Move Normal

Workup Chest X-ray CBC Complete urine count

Asessment Ca mammae sinistra Dyspnoe e.c metastasis pleura Limfodenitis

Management O2 4 lpm IVFD RL 10 tpm If leucocytosis Ceftriaxon 2x1gr iv

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Case 3

Identity Name : Mr. TB Age : 22 y.o Sex : Male Address : Camplong

History Taking Chief Complaint: Burn wound

Present Complaint: Patient presented w/ painful burn wound existed from a day ago, resulted from falling on top of a flaming cooking stone stove while squatting in front of it. Toothpaste was applied on his burn wound before he was admitted at RS Naibonat.

Physical Examination Primary Survey

A: Clear B: spontaneous breathing with RR of 20 C: Pulse rate: 88 D: Alert (GCS: E4V5M6)

Secondary Survey Hair : Black, Allopecia (-) Eyes : Conjungtiva : Anemic (-/-) Sclera : Icteric (-/-) Ears : Normal Nose : Normal Mouth : Normal Neck : Lymphadenopathy (-)

Physical Examination PULMO

Inspection: symmetrical chest expansion Palpation : Vocal fremitus (d=s), mass (-),

crepitation (-) Percussion: sonor (+/+) Auscultation : Vesiculer (+/+),Ronchi (-/-),

Wheezing (-/-) COR

S1/2 single, murmur (-), gallop (-)

Physical Examination ABDOMEN

Inspection : Flat, suitable with breathing Auscultation : normal peristaltic sound Palpation : Tenderness (-) Percussion : Tympanic sound

Local status Location; face, neck, distal 2/3 of the left

arm, medial 1/3 of right upper arm.

Lab ResultsDL

WBC: 24,64 Lymph: 1,84 Mono:1,48 Eo:0,52 Baso: 0,03 Neut:20,77 RBC13,56 HGB 14,9 HCT 43,6 MCV 78,4 MCH 26,8 MCHC 34,2 PLT 206

UL BJ: 1.020 pH 6,0 Lekosit +3 Nitrit (-) Glukosa N Protein N Urobilinogen N Keton (-) Bilirubin (-) Eritrosit +3

Sedimen•Lekosit penuh•Eritrosit 15-20/lp•Epitel 15-20/lp•Silinder (-)•Kristal (-)•Bakteri (-)

Lab Results Ureum 16,1 Creatinin 0,3 GDS 133 Na 137 K 4,2 Cl 104

Planning Plasma Albumin

Assessment Grade 2 burns with 17% body area

involvement

Planning Therapy Wound Toilet Burnazine zalf Inj ATS 1 amp IM IVFD RL 20 tpm Inj. Omeprazole 1 amp IV Inj. Cefotaxime 2x1 gr IV