Morning Report April 1st 2013

Resident On Duty : Dr.Winardi Coass On Duty : Dimas

Minor Surgery = 2 Patients Plastic Surgery = 0 Patient(s) Orthopaedi = 0 Patient Urology = 0 Patients Pediatric Surgery = 0 Patient(s) Neurosurgery = 0 Patient Oncology = 0 Patients Thorax & Cardiovascular = 0 Patient Digestive = 0 Patient

Total New Patients = 2 Patients All Patient will be reported

No

Identity

Admission to E.R.

Diagnosis

Treatment

Planning

1.

Mrs. Marpuah/47 yo/ASKES

April 1st 2013 at 10.10

Debridement Vulnus Cross insisi laceratum+Vulnus felix Antibiotic a/r cruris sinistra Analgetic Anti Tetanus profilaksis

Discharged by permission

2.

Mrs. Rusyidah/36/A SKES

April 1st 2013 at 10.40

Corpus alineum a/r pedis sinistra

Debridement Cross Insisi Antibiotic Anti Tetanus profilaksis

Discharged by permission

 Chief Complain : Cat Bite History :

about 3 hours before admission, patient was bitten by cat at when he was walking around her home. Suddenly her leg was bitten by cat, and it made swelling (+), pain (+), bleeding (-).

Clear, snoring (-), gurgling (-)

Clear, RR=28x/min, symmetric respiratory movement

BP: 100/70 mmHg, Pulse rate: 78 x/m regular GCS E4V5M6, round and symmetric pupils diameter (3mm/3mm), light reflexes (+/+), no paralysis

A M

P L
E

Home

Head/Neck

Eye : anemic conjunctivae (-/-), icteric sclerae (-/-) Mouth : Wet mucosa, perioral cyanosis (-) Neck : increase of JVP (-)

Chest

I : symmetric respiratory movement, retraction (-), P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen

I : Flat, hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Extremities

Warm periphers, edema (-), paralysis (-)

VL + Vulnus Felix a/r Cruris sinistra

Debridement + Cross insisi Antibiotic Analgetic Anti Tetanus Profilaksis

 Chief Complain : pain at left foot History :

1 day before admittion, patient strucked by wood at left foot when she was walking at her . She didnt wearing sandals. The patient feel pain at her left foot. Bleeding(+) not active, swelling (+), pain (+).

Clear, snoring (-), gurgling (-)

Clear, RR=20x/min, symmetric respiratory movement

BP: 120/70 mmHg, Pulse rate: 88 x/m regular GCS E4V5M6, round and symmetric pupils diameter (3mm/3mm), light reflexes (+/+), no paralysis

A M

P L
E

Home

Head/Neck

Eye : anemic conjunctivae (-/-), icteric sclerae (-/-) Mouth : Wet mucosa, perioral cyanosis (-) Neck : increase of JVP (-)

Chest

I : symmetric respiratory movement, retraction (-), P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen

I : Flat, hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Extremities

Warm periphers, edema (-), paralysis (-)

Corpus Alineum a/r pedis sinistra

Debridement + Cross insisi Antibiotic Analgetic Anti Tetanus Profilaksis

 Chief Complain : open wound at lip History :

8 hours before admission, the patient was falling from motorcycle whem he try to avoiding hole in the road. The patient wearing helmet with medium speed. Unconscocious(+) for 30 minutes. Bleeding from M/E/N (-/-/-). Nausea/Vomitting(-/-)

Clear, snoring (-), gurgling (-)

Clear, RR=20x/min, symmetric respiratory movement

BP: 110/80 mmHg, Pulse rate: 86 x/m regular GCS E4V5M6, round and symmetric pupils diameter (3mm/3mm), light reflexes (+/+), no paralysis

A M

P L
E

Road

Head/Neck

Eye : anemic conjunctivae (-/-), icteric sclerae (-/-) Mouth : Wet mucosa, perioral cyanosis (-) Neck : increase of JVP (-)

Chest

I : symmetric respiratory movement, retraction (-), P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen

I : Flat, hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Extremities

Warm periphers, edema (-), paralysis (-)

STATUS MAXILOFACIAL

REGIO FRONTALIS INSPEKSI : Hematom (-), luka (+), jejas (+) Palpasi : krepitasi (-), nyeri tekan (+) REGIO PERIORBITA DEKSTRA Inspeksi : hematom (-), luka (-), jejas (-) Palpasi : krepitasi (-), nyeri tekan (-) REGIO PERIORBITA SINISTRA inspeksi : hematom (-), luka (-), jejas (-) palpasi : kepitasi (-), nyeri tekan (-) REGIO ZYGOMATICUS DEXTRA inspeksi : Hematom (-), luka (-), jejas (-) palpasi : Krepitasi (-), nyeri tekan (-) REGIO ZYGOMATICUS SINISTRA inspeksi : hematom (-), luka (-), jejas (-) palpasi : Krepitasi (-), nyeri tekan (-) REGIO CHEEK DEXTRA inspeksi : Hematom (+), luka (-), jejas (-) palpasi : krepitasi (-), nyeri tekan (+) REGIO CHEEK SINISTRA inspeksi : hematom (+), luka (-), jejas (-) palpasi : krepitasi (-), nyeri tekan (-)

REGIO NASAL inspeksi : hematom (-), luka (+), jejas (+) palpasi : krepitasi (-), nyeri tekan (-) DENS labialis superior : luka (-) labialis inferior : luka (+) membuka mulut : luka (+) maloklusi :REGIO MENTALIS inspeksi : hematom (-), luka (+), jejas (+) palpasi : krepitasi (-), nyeri tekan (+) REGIO CORPUS MANDIBULA inspeksi : hematom (-), luka (-), jejas (-) palpasi : krepitasi (-), nyeri tekan (-) REGIO COLLUM MANDIBULA inspeksi : hematom (-), luka (-), jejas (-) palpasi : krepitasi (-), nyeri tekan (-)

Multiple VE a/r Facialis, Antebrachii Dextra et Sinistra + VL Labialis Oris + Susp. # simfisis mandibula sisnistra

Debridement + Primary suture Antibiotic Analgetic

 Chief Complain : open wound History :

One day before admission, the patient was strucked by zink at her 3rd finger of left foot. She didnt wear sandals or shoes. The wound has gave with garlic. The patient complained febris about 5 hours before admission.

Clear, snoring (-), gurgling (-)

Clear, RR=20x/min, symmetric respiratory movement

BP: 120/80 mmHg, Pulse rate: 88 x/m regular GCS E4V5M6, round and symmetric pupils diameter (3mm/3mm), light reflexes (+/+), no paralysis

A M

P L
E

Home

Head/Neck

Eye : anemic conjunctivae (-/-), icteric sclerae (-/-) Mouth : Wet mucosa, perioral cyanosis (-) Neck : increase of JVP (-)

Chest

I : symmetric respiratory movement, retraction (-), P : symmetric VF P : Sonor in all lung field A : symmetric VBS, Rh (-/-), Wh (-/-)

Abdomen

I : Flat, hematoma (-) A : Normal bowel sound P : H/L/M not palpable, tenderness (-), mass (-) P : Tympanic in all quadrants

Extremities

Warm periphers, edema (-), paralysis (-)

VL a/r Digiti III pedis sinistra

Debridement + Primary Suture Antibiotic Analgetic Anti Tetanus Profilaksis