SURGERY MORNING REPORT
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Transcript of SURGERY MORNING REPORT
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8/12/2019 SURGERY MORNING REPORT
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Emergency Unit
Night Shift ReportMarch, 18th2014
Assistant:
Dr. Hendy Sibuea
Co-assistant:
Renol (chief)
DeboraTiur
Metiel
Septa Tio
Hizkia
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1. Ms. S (36Years Old)09400500
Mechanism of the Trauma
Unknown
Injury of target organ
Head
Symptoms and signs
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Treatment Pre Hospital (Before UKIS ER) Wound Toilet,
Hecting,
Oxygenization,
IVFD; Ringer Lactate
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PRIMARY SURVEY
Airway : CLEAR
Look : no obstruction
Listen : no extra breath sound (no gurgling, no snoring,
no stridor, no horseness) Feel : there were warm air from both nose and mouth
Breathing : CLEAR
Inspection: bruise (-), chest wall movement
symmetrical, RR 20 x/min, hematoma ()
Pal : crepitation (-)
Per : sonor right = left
Aus : Basic breath sound bronchial, rh -/-, wh -/-
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Circulation : No Sign Of Shock
Warm extremities,
Pulse = 100 x/menit Bp = 110/70 mmHg
Temp= 36,50C
CRT
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Secondary Survey
Chief complaint : Pain on bruises in Face
and others
Additional Complaint : Pain on Abdominal
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History of illness
Patient came accompanied with her
family to UKIs ER reffered by
TEBET HOSPITAL in case of
Trauma. The history of trauma isunknown. Patient came to TEBET
HOSPITAL at 2 pm and transfered to
UKI HOSPITAL at 9 pm. The familyalso didnt know what happened to
the patient. Patient came conscious
but her jaw was broken she couldnttalk.
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HEAD TO TOE
Head : Normocephaly
Eyes : Pupil circular, isochoric 3mm/3mm,centered, Direct Light Reflex +/+, Indirect
Light Reflex +/+, CA +/+
Ear : normal, LCS (-), blood (-)Neck : Bruise (-), hematoma (-)
1. Vulnus excoriation on regio maksilofacia
2. Vulnus laceratum on regio frontalisregio nasal, and regio auris destra
et sinistra (covered by bandage)
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Thorax :- Inspection : bruise (-), movement of chest wall
symmetrical
- Palpation : crepitation (-), palpation pain (-)
- Percussion : sonor right = left, percussion pain
(-)
- Auscultation: Basic breath sound Vesicular
right=left, wh-/-, rh-/-.
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Abdomen
- Inspection : flat, bruise (-),
- Auscultation : bowel sound (+) 5x/min
- Palpation : tenderness (-), defense
muscular (-)
- Percussion : tympani, percussion
pain (+)
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In NGT bag, seen black fluid
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Superior Extremities
Warm, CRT
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Inferior Extremities
Look: edema (-), hematoma (-), rotation (-), Vulnusexcoriation and vulnus laceratum on digiti 1,2 regio pedis
dextra
Feel: pain on palpation (+), crepitation (-)
Move: active with no limitation
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CT Brain:
Bone Window
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CT Brain : Fraktur Corpus Os Mandibula
dextra + Proc. Zygomaticus
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CT Brain :Brain Window
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Laboratory Findings
Hb : 8.6
Leu : 16.770
Ery : 3.860.000
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AMPLE
Allergy : -
Medication : -
Past Illness : -
Last Meal : unknown
Event : Traffict Accident
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Working diagnose
Mild Head Injury + Suspect Intra Abdominal
Bleeding + Anemia + Fractur Corpus Os
Mandibula Dextra + protuberentiaMandibula Dextra + Proc. Zygomaticum +
Vulnus Excoriation + Vulnus Laceratum
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TREATMENT
Non Medicamentosa :
Hospitalized Diet:
Calori needed 30cc/kgbb/hari
Partial Parenteral Nutrition
Medicamentosa :
IVFD :
Futorolit 30mg/kgbb/hari (kristaloid + dextrose) * =
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TREATMENT
Medica Mentosa
Omeprazole (ppi) tab 2x40mg
Ketesse (analgetik) tab 3x35mg
Vit K inj Meropenem inj 3x500mg
Transfusion Planning PRC 300 cc
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Planning
Maintenance
Observation :
Conciousness, Vital Sign
NGT until the fluid is clear
Nutrition :
Changing of nutrition uptake
Surgical Planning:Orif
Consul: Mouth Surgery