Morning Report

Departement of Surgery
February 15rd 2017
List OB Bedah 15/2/2017

1. Tn. amin / 60 th/ colic renal dex, UTI, AROFAH 1

2. Ny adi nugroho/ 40th/ vulnus laceratum genue sin pro debridement OK
3. tn parto /68 th/ nephrolithiasis dex, SH Marwah 1
4. An yayah/ 13th/ vulnus laceratum tempporal sin+ COR+ internal bleeding
dengan hemodinamik stabil OK
5. An amiro/ 13th multiple vulnus eksoriatum+ fr nasal OK
6. Tn supar / 53th vulnus laceratum temporal dex OK
7. Nn lailatul/ 17 th COB Meninggal
8. Ny supiah / 50 th COR RJ
9. TN Subram /26th CF cruris 1/3 medial sin shofa 3
10. An rinyani r / 8 th
Identity

Name : An y
Age : 13years old
Occupation : student
Address :sidayu, Lamongan
Admission : February 15nd, 2017 at 17.00 PM
Anamnesis

Chief Complain:
post accident abdominal pain
Present History:

Patient came to emergency room RSML with chief complaint of abdominal pain
since 2 hour before admission. The patient felt persistent pain the most at right
upper abdominal area. The pain was not relieved with medication. The patient
also had headache, nausea, vomiting twice after accident. the patient also
noticed wound and swelling upper left eye. There was no complaints lost of
consciousness, seizure abnormal vision, ear and nose bleeding.
MOI: Patient rode motorcycle with high speed and didnt put any helmet. when
patient passed road turning, she crashed other parked motorcycle. She fell with
her upper left eye crashed asphalt and her stomach crashed handlebar.
 Past Illness History:
Alergi -
Family History:
-
Vital Signs

BP
133/68 mmHg
Pulse
107x/min
Temp
36C
RR
20x/min
Primary Survey

A: clear, gargling (+), snoring (-), speak fluently (-), potential obstruction (+)
B: spontaneous, RR 20x/min, ves / ves, rh -/-, wh -/-, SaO2 100% without O2
support.
C: extremity WDR, CRT <2, N 107x/min, BP 133/68 mmHg
D: GCS 456, lat-, PBI 3mm/ 3mm, LP +/+
E: temp 36 C
 GENERAL STATUS
General condition : weak
GCS : 456
H/N : a -/i-/c-/d-
Vulnus laceratum et regio temporal sin tepi ireguler ukuran 10cm x 5cm dasar
subcutis.
Multiple vulnus ekskoriatum.
lymph node enlargement at neck (-)
JVP within normal limit
Thorax
Inspection
Symmetrical, retraction -
Palpation
Thrill -, fremitus WNL
Percussion
Lungs: sonor / sonor
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh -/-
Cor: S1S2 single, M -, gallop -
Abdomen
Inspection
Flat, symmetric
Auscultation
Met -, bowel sound WNL
Palpation
Pain (+ )RUQ. Liver/Spleen within normal limit
Percussion
Tymphany,
Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-), edema (-)
Palpation
Acral: warm dry red, CRT <2
CLUE AND CUE

female , 13 y.o.
post accident
abdominal pain
right upper abdominal area
headache, nausea, vomiting
Vulnus laceratum et regio temporal sin tepi ireguler ukuran 10cm x 5cm dasar
subcutis.
Initial Diagnose
Susp. Internal bleeding
COR
Vulnus laceratum regio temporalis sin.

Planning diagnose
DL
GDA
Ct scan
USG FAST
Laboratory Examination
USG FAST CT SCAN
Complete Blood
Count Tampak fluid pada Dalam batas
Leukosit 25,6 daerah morison normal
Neutrofil 88 pouch dan para
Limposit 3,5 vesica minimal
Monosit 5.9
Eosi 0,7 Tampak
Basofil 1,6
Eritrosit 3,88 peningkatan gas
Hb 11 g/dL usus pada daerah
Hematokrit 33,7% nyeri sekitar
Mcv 85,8 epigastrium
Mch 28,4
Mchc 33
Trombosit 318.000
LED 1/ 2 = 5/14
CT SCAN
Diagnose

Internal bleeding dengan hemodinamik stabil

COR
Vulnus laceratum regio temporalis sin.
 Planning Therapy
O2 nasal 2 lpm
Pasang DK
Inf. Asering Loading 2000cc 1500cc/24 jam
Inj. Ceftriaxon 2x1 gr
Inj. Na. Metamizole 3x1gr iv
Inj. Ranitidine 2x50 amp iv
Inj. Ceteron 8 mg prn
Inj tetagam
Inj piracetam4x 3 gr
Consul Surgeon debridement + repair.