MORNING REPORT

30-5-2013
RESUME
Identity Diagnose Therapy
Mr. KL, 19 years old,
protestan, Tilong
Vulnus laceratum regio
genu sinistra
Wound toilet
Hecting
ATS inj/ im (skin test)
Amoxycilin 3x1 tab
Antalgin 3x1 tab
Observation
outpatient
Mss. BS, 50 years old,
protestan, labat
Vulnus ekskoriasis regio
facial and volar manus,
Vulnus laceratum regio
nasolabialis dextra
Wound toilet
IVFD RL 20 drops per
minute
Ranitidine 1 amp inj/IV
Piracetam 3gr inj/IV
outpatient

Identity Diagnose Therapy
Mr. DR, 58 years old,
protestan, Oepura
Colic abdomen e.c.
Urinary tract infection
Ddx/ urolithiasis
Kaltrofen supp 2 x 1
Control policlinic
Mr. FS, 20 years old,
protestan, Maulafa
Electric Injury Ketorolac 30 mg inj/IV
Observation
Out patient
Identity Diagnose Therapy
Mr.DN, male, 13 y.o Vulnus laceratum et
auricula sinistra

Wound toilet
Hecting
Amoxiciline 3x500 mg
Mefenamat Acid 3x500
mg
ATS 1 amp/IM
Mrs. R, female, 31 y.o Vulnus laceratum et pedis
dextra

Wound toilet
Hecting
Amoxiciline 3x500 mg
Mefenamat Acid 3x500
mg
Identity Diagnose Therapy
Mr. EH, male, 46 y.o Vulnus laceratum et regio
occipitalis + mild head
injury
Wound toilet
Hecting
ATS 1 ampule/ IM
CT-SCAN kepala
Amoxiciline 3x500 mg
Mefenamat Acid 3x500
mg
SB, male, 14 y.o Susp. Closed fracture of
antebrachii dextra +
Multiple vulnus
excoriatum

KTC 3% 1 amp/IV
Retractioni + Gypsung
X-ray of antebrachii
region (AP Lat)
Identity Diagnose Therapy
Mr. TH, 53 y.o, farmer Vulnus ictum et digitus
index and medius
Cross incision+Hecting
Diclofenic sodium 3x500
mg
Dexamethason 3x10 mg
Mr.VP, 25 y.o,
unemployer
Mild head injury
Multiple vulnus laseratum
& excoriatum
- IVFD RL 20 tpm
- Ketorolac inj. 3% IV
- Ranitidine inj. 25 mg
IV
- Piracetam inj. 3 gr IV
- Cefotaxime inj. 1 gr IV
Mr.VH, 21 y.o. student Susp. Acute Appendiscitis - Ketorolac inj. 3% IV
BIODATA
Name : Mr. VP
Age : 28 years old
Sex : Male
Address : Camplong
Job : Unemployed

Anamnesis
Chief Complaint :
motor cycle accidence
MOI
The patient came to ER because he got motor cycle accidence couple hurs ago.
Patient has loss of consciousness and several wounds on his face, chest and
legs. History of taking alcohol (+), nause (-). Vomit (-), bleeding for ear canal
& nose (-)




Primary Survey
A: clear
B : RR: 52 times in a minute
C : Blood preasure : 130/80 mmHg , Pulse:
92 times/minute, reguler.
D : GCS E1V2M1
E : vulnus laseratum et regio frontalis,
nasolabialis & mentalis. Vulnus excoriatum
et regio thorax dextra, epigastric sinistra,
cubitalis posterior & femur dextra
Secondary Survey
GCS : E1V2 M1
Eye : anemic (-/-), light reflex (+/+), icteric
(-/-)
Ear : In normal limit
Nose : In normal limit
Throat : Normal
Thorax
Inspection : chest development simetrics,
reguler, abdominothoracal
Palpation : vocal fremitus R=D
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)

Abdomen
Inspection : distended (-)
Auscultation : peristaltics + normal
Palpation : tenderness pain (-) , mass (-)
Percusion : timpany sound (+)

Extremity

Look
normal
Feel
normal
Move
ROM : normal

Laboratorium
WBC : 20.1 x 10
3
/uL
RBC : 7.27x10
6
/uL
HGB : 15.7 g/dL
PLT : 361 /uL






Assessment
- Severe Head injury
- Multiple Vulnus laseratum + excoriatum
- Alcohol intoxication
Planning therapy
Planning dx = Head CT-Scan
IVFD RL 20 tpm
Ketorolac Inj. 3% IV
Ranitidine inj. 2 x 1 Amp IV
Piracetam inj. 4 x 3 gr IV
Cefotaxime inj. 2 x 1 gr IV
Observe vital sign
BIODATA
Name : Mr. VH
Age : 21 years old
Sex : Male
Address : Maulafa
Job : Student

Anamnesis
Chief Complaint :
Pain on the lower right abdomen
MOI
The patient came to ER because he suffer from abdominal pain especially on
the lower right region since 1 day ago. History of fever (+), nause (-). Vomit
(-), difficult in defecation (+) since 2 days ago, anorexia (-), difficult in
urinating (-), history of same complaint (-0





Secondary Survey
GCS : E4 V5 M6
Eye : anemic (-/-), light reflex (+/+), icteric
(-/-)
Ear : In normal limit
Nose : In normal limit
Throat : Normal
Thorax
Inspection : chest development simetrics,
reguler, abdominothoracal
Palpation : vocal fremitus R=D
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchie (-/-),
wheezing (-/-)

Abdomen
Inspection : distended (-)
Auscultation : peristaltics + normal
Palpation : tenderness pain (+) on the lower
right quadrant , DM (-), mass (-)
Percusion : timpany sound (+)

Extremity

Look
normal
Feel
normal
Move
ROM : normal

Laboratorium
WBC : 13.0 x 10
3
/uL
Neut# : 83.7%
RBC : 5.83/uL
HGB : 16.4 g/dL
HCT : 48.9%
MCV : 84 Fl
MCH : 28.1 pg
MCHC : 33.5 g/dL
PLT : 209 /uL


Urinalysis
Lekosit (-)
Protein (-)
Keton (-)
Urobilinogen normal
Eritrosit (-)
Sedimen urine
Lekosit (-)
Eritrosit (-)
Epitel 2-4/LP

Alvarado Score
Appendicitis point pain 2
Leukositosis (>10.000) 2
Vomitus -
Anorexia -
Rebound tenderness Phenomen 1
Abdominal Migrate Pain -
Degree of celcius (>37,5
o
C) -
Observation of Hemogram (segmen >72) 1
Total Point = 6 Possible Appendiscitis
Assessment
Susp. Acute Appendiscitis
Planning therapy
Bedrest = Fowler position
Ketorolac Inj. 3% IV
Observe vital sign
THANK YOU