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Morning Report

Dimas Adi Soewignyo


Identity
Name: Tn. D.R
Sex: Male
Age: 22 years
Religion: Islam
Occupation: Private
No. Medical record: 075971
Anamnesis/Aloanamnesis
Patient was hit by 1 people with bare hand at 23.00 on
Saturday 9th 2017
Patient was hit in right stomach, left eye, and left upper lip
Patient came to the emergency department with investigator
and his younger sister
Vital sign
GCS = E4V5M6
Blood pressure 120/80 mmHg
Heart rate 80x/min
Respiratory rate 20x/min
Temperature 36,7C
Wounds description
An abraded wound with round-shaped was found in left
upper lips
The size was 1 x 0,7 cm
The color of wound base was blackish red
there was a tissue bridge, wounds edge was not flat. The cliff
of wound consist of mucosa.
Therapy
Administration of pain killers (Asam mefenamat)
Conclusion
From the facts found from the examination of the patient, I
conclude that a 22 years old man has been examined with good
nutritional status (Height: 166 cm, Weight 54 kg) and appears
fully conscious. An abrated wound was found in left upper lips.
The healing time is estimated between 1 - 2 weeks. During
During the healing period of wound, the victim can perform
daily activities