MORNING REPORT

19-02-2013

BIODATA
Name : Tn. PN Age : 25 years old Sex : Male Address : Pasir panjang Job : Fisherman

Anamnesis
Chief Complaint :
blood realese from mouth

History
patient came to the ER because he has blood release from his mouth, patitient is the victim from motorcycle accident. Time of the accident, the patient was not wearing a helmet. The patient was unconscious for 30 minutes.

Primari Survey
A: clear B : RR: 23 times in a minute C : Blodd preasure : 120/70 mmHg , Pulse: 120 times/minute, reguler. D: E : Vl et regio frontalis

Secondary Survey
GCS : E3 V5 M6 Eye : anemis (-/-), pupils refleks +/+, icteric (-/-) Ear : othoroe (-/-) Nose : rhinoroe (-/-) Throat : Normal

Toraks
Inpection : chest development simetrics, reguler, abdominothoracal Palpation : vocal fremitus R=D, crepitation (-) Percusion: sonor (+/+) Auscultation : vesicular (+/+), ronchie (-/-), wheezing (-/-)

Abdoment
Inspection : suffle, distended (-), Auscultation : intestinal sounds + normal Palpation : tenderness pain (-), mass (-) Percusion : timpany sound (+)

Extremitas
Look normal Feel normal Move
ROM : Limited

Assessment
Mild Head Trauma + VL regio frontalis

Planning Therapy
IVFD RL 20 drops per minutes Inj. Ketorolac 3% 3x1 amp IV Inj. Ranitidin 1 x 50 mg IV Inj. Piracetam 3 x 1 amp IV Inj. Cefotaxim 2x1 gr IV X-Ray Skull potition Ap/Lat

THANK YOU