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Morning Report

July 28th 2018 (14.00-


DM Gesta
21.00)
Surgery Dept. Counsultant DM Yovie
PATIENT I

Name : Mr. KK
Age : 51 years old
Gender : male
Address : Rote
MR : 49-66-45
HISTORY TAKING
Data was collected in emergency room on July 28th 2018, from autoanamnesis and
alloanamnesis with the patient’s wife at 20.15
Chief complain: heavily of breath
Current History : this patient was reffered from RS. Baa, with heavily of breath after
accident on Thursday 26/7. at the moment patient bring his customer and ride his
motorcycle, suddenly a dog cross his way with speed 60 km/hr then patient
suddenly stop and fall down in left side, his chest hit the ground and patient
become unconsciousness. His wife said from the witness in location there was no
history of seizure and vomit, patient became unconscious for a day, there was
bleed from his right ear, nose and mouth.
Now patient also complaint that he feel hurt on his left shoulder.
PRIMARY SURVEY
A : Clear
B : abdominal, RR : 31x/min, assimetry,
C : BP : 140/90 mmHg, HR : 114 x/min, regular
D : GCS E4 V5 M6
E : multiple vulnus excoriatum on left shoulder, left hip, left
antebrachii, dorsum manus R/L, knee R/L
SECONDARY SURVEY

GCS : GCS E4 V5 M6, good orientation of time and people


Head : lesion (-)
Eye : palpebral edema(-/-), pupil isocor, direct light reflexes +/+
Ear : dry hemorhagi +/-
Nose : Epistaxis -/-
Neck : Lesion (-), normal neck movement
THORAX
Lesion (-) VE angulus sterni, scar (-)
Lung
Inspection : asymmetrical chest expansion delayed left chest
Palpation : Vocal fremitus (R≠L), pain (+), crepitation (+)
sinistra, emphysema subcutis D/S
Percussion : hipersonor/redup
Auscultation : Vesicular (↓/↓) , Ronchi (-/-), Wheeze (-/-)
Cor
Single S1/S2, murmur (-), gallop (-)
ABDOMEN

Abdomen
Inspection : flat, lesion (-)
Auscultation : normal peristaltic sound 12x/m,
Palpation :
 Distended (-) epigastric pain
Percussion :
 Tympani (+) all regio
UPPER & LOWER LIMBS
Upper Limb
Look : lesion (+) VE antebrachii sinistra, dorsum manus dex et sin,
deformity(-)
Feel : warm, CRT < 2 seconds

Lower Limb
Look : multiple VE (+) on genu dextra et sinistra
Feel : warm, CRT < 2 seconds
LOCALIZE
STATUS
multiple vulnus excoriatum on left
shoulder, left hip, left antebrachii,
dorsum manus R/L, knee R/L
LAB
Hb : 11.2
Ht : 31.6
Rbc: 3.77
Wbc: 8.78
Plt: 247
GDS: 103
BUN: 17
Cr: 0.95
Na: 136
K : 4.1
ASSESMENT

Minor Traumatic Brain Injury


Hematopneumothorax
Fr costa 2 lateral, 4,7,8,9 posterior
sinistra
Emphysema subcutis
Multiple VE
PLANNING
IVFD NaCl 0,9% 20 gtt
Inj ceftriaxone 2x 1gr
Inj ketorolac 3x 30mg
Inj ranitidine 2x 50mg
Pro WSD
PATIENT II

Name : Mr. MM
Age : 54 years old
Gender : female
Address : Rote
MR : 142639
HISTORY TAKING
Data was collected in emergency room on July 28th 2018, from autoanamnesis and
alloanamnesis with his family at 20.00
Chief complain: weaknesss
Current History : patient feel weak and cant stand since a month ago, when she
became lack of appetite. Patient complaint pain on his stomach and difficult to
explain how worst it is and the location. Sometimes patient experience vomit and
nausea. Patient also complain a wound on her right foot it experience since a year
ago, her foot was pricked by thorn and the wound getting worst and never heal, so
patient check to Puskesmas and found that she had Diabetic
Previous history: uncontrolled DM type II
PHYSICAL EXAMINATION
PEMERIKSAAN FISIK

General app : mild


Conciousnes : CM
GCS = E4V5M6
BP : 140/80 mmHg
Temp : 37.5 derajat Celcius
(aksiler)
pulse : 76x/min, reguler, strong
RR : 20 x/m
SpO2 : 99% with O2 4 lpm
SISTEM ORGAN
• head : normocephal, black hair,
simetricly face.
• Nose : sekret (-/-), epistaksis (-/-)
• Kulit : cyanosis (-),jaundice(-)
• Mouth: cyanosis (-), dry lips, gingiva
bleeding(-)
• Mata : conjunctiva anemis (-/-),
Sklera icterus (-/-), konjungtiva
• Neck : enlarged tyroid(-), enlarged
bleeding (-/-)
lymph nodes (-)
• Ear : Deformity (-/-), otorea (-/-)
• Toraks : normal shape,assimetric,
scar (-)
SISTEM ORGAN
• Pulmo: ves/ves rh-/- wh-/-
• Cor: s1 s2 murmur (-) gallop (-)
• Abdomen: bowel sound (+)
Pain on
- - +
- + +
- + +

• Extremity: warm CRT <2”, ulcus on


right foot with bone as based
LOCALIZE
STATUS
Ulcus 4x5cm with bone surface
ASSESMENT

Diabetic foot dextra


DM type II
Abdominal pain Susp
Gastrophaty diabetic
PLANNING
IVFD NaCl 0,9% 20 gtt
Inj omeprazole 2x 40mg
Sucralfat syr 3x C1
Wound toilet