MORNING REPORT

24-06-2017

DM. Hilda, DM Eus dan DM. Wily

 IDENTITY
Name : An. CL
Age : 6 years old
Sex : Female
Address : SOE
Reffered from RSU Soe, Juny 24, 2017
 History Taking
Chief Complaint : Wound at right face and right foot
Moi :
Patient reffered from RSU Soe with moderate head injury
after the motorcycle accident. The patient ride motorcyle
with her father, older and younger sister. While on the
way suddenly cows come from the left side and
immediately fell forward towards the right and hit the
asphalt. Just her father who use the helmet. She and her
sister didnt take a helmet when the accident happen.
she was consious after the accident until now. Headache
(+), Vomit (-), nausea (-),
 Physical Examination

Primary Survey :
Airway : Patent, clear
Breathing : Spontan, 22x/m
Circulation : BP : 100/80 mmHg, N : 80 x/m,
Disability : Alert, GCS E4V5M6
Exposure :
Vulnus laseratum regio frontal dextra
Multiple vulnus ekskoriatum regio facial dextra and
cruris dextra
Hematom periorbital dextra
 Secondary Survey
Head/Face :
Vulnus laseratum regio frontal dextra and vulnus
eskoriotum regio facial dextra
Eye : Anemic (-/-), pupil isokor (+/+), icteric (-/-)
Ear : Ottorea (-/-), bekas perdarahan (-/-)
Nose : Rhinnorea (-/-), bekas perdarahan (-/-)
Neck : Lymphadenopathy (-)
 Physical Examination
Lung
Inspeksi : Chest expansion symetric, retraction (-)
Palpasi : Vocal fremitus (R=L), mass (-), krepitasi (-)
Perkusi : sonor (+/+)
Auscultasi : Vesiculer (+/+) , Ronchi (-/-), Wheezing (-/-)
Heart:
S1/S2 single, murmur (-), gallop (-)
Abdomen
Inspeksi : Flat
Auskultasi : peristaltic sound normal
Palpasi:
flexible, Tenderness (-)
Percussion :
Tympani
Extremities
Look : Vulnus ekskoriotum regio cruris dextra
Feel : warm, pain (+) around the wound
Move : ROM is limited
 Assesment
Mild head injury
Open fraktur depressed frontal dekstra
 Therapy
Wound Toilet
IVFD NS 0,9% 500 CC 20 Tpm
Inj. Ketorolac 2 x 15 mg
Inj. Ranitidin 2 x 25 mg
 Planning
Ct- scan kepala
Consul SpBs
Craniotomy debridement
TERIMAKASIH