MORNING REPORT

TH
APRIL 29 2013
Konsulen dr. Jean Pello, SpB

1St Case

BIODATA

Name : MD
Age : 4 years old
Sex : Male
Address : Sikumana

Anamnesis

Chief Complaint : Fell from the car

MOI
patient come to ER because of falling from the parked car several
minutes ago. The child cry a lot and blood was over the face. Theres a
wound at the right forehead. The kid didnt loss the consciusness, no
nausea, no vomit, but theres headache presents. Theres no other
wound or other complaints.

Primary Survey

A: Patent, clear
B : RR: 24 times/min, spontan
C : CRT : <2, Pulse: 92 times/minute, reguler.
D : GCS E4V5M6
E : V. Laceration on region Frontal dextra, 2cm

Secondary Survey

GCS : E4 V5 M6
Head : Normal
eyes : anemic (-/-), light reflex (+/+), icteric (-/-) ,
isokhor +/+
Ear : normal
Nose : normal
Neck: Normal

Thorax

Inspection : chest expansion simetrics, reguler,

abdominothoracal, Bruish (-)
Palpation : vocal fremitus R=D, krepitasi (-),
Pain (-)
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchi (-/-),
wheezing (-/-)

Abdomen

Inspection : look flat, follow the chest

expansion
Palpation : pain (-), mass (-), tenderness (-)
Percusion : timpany (+)
Auscultation : peristaltics (+), normal

Extremity
Look

(normal)
Feel normal
pain (-)
Move
ROM

: normal

Assessment

Vulnus laceratum at regio frontal dextra

Planning therapy

Wound toilet and primary hecting

Anti tetanus serum
Paracetamol 250 mg 3x1 tab
Amoxicillin 250 mg 3x1 tab

Picture

Patient Identity

Name
Sex
Age
Religion
Job
Adress

: Mrs. WN
: Female
: 51 y.o
: Catholic
: Housewife
: Soe

History

Chief complaint: shortness of breathe 2 days before

hospitalize
MOI:
Shortness of breath has been felt for a long time, experienced again 2
days after patient received an introductory home from the hospital.
Patients treated till date 21/03/14 04/26/14 26 with a diagnosis of ca.
mammary sinistsra. Ca experienced since 2009, breast surgery. In
2012 appeared the bump, bump in 2013 turned into a wound. August
2013 appear small bumps around the left breast to the right spread to
the neck and armpits. The bumps on the left side neck pain when
touched. Because it is often shortness of breath, in 2014 the patient
had 6 times the puncture lung fluid, four times in the left lung and right
lung 2 times. Bumps that have become wound was cut then sent for
examination, then the result is 2 weeks out. 2 months ago while being
treated, the patient's legs and hands swelled. History urinating blood
while being treated. unconsciousness (-), nausea (+), vomit (-),
dizziness (-).

Habit history: smoke five to six cigarettes / day

since the age of 21 years and drank alcohol

Primary Survey

Airway: clear
Breathing: 36 x/min

Circulation:

Pulse: 97x/min

Disability: E4V5M6
Exposure : covered with gauze

Secondary Survey

GCS E4V5M6
Head: simetric, normocephal
Eye : anemic (-/-), light reflex (+/+), icteric (-/-),
isokor (+/+)
Ear : Normal
Nose : Normal
Mouth : Normal
Neck: enlarged lymph nodes (+), multiple, cervical
region, axilla region, chest region. Size: 1cm,
elastic, immobile, tenderness (+)
Throat : Normal

Thorax
Inspection

: chest expansion simetrics, reguler,

Palpation : edema (-), crepitation (-), tenderness (-)
Percusion : sonor (+/+)
Auscultation : vesicular (+/+), ronchi (+/+), wheezing(-/-)

Abdomen
Inspection

: flat, mass (-), wound (-)

Auscultation : peristaltics (N)
Palpation : tenderness pain (-)
Percussion : timpanic sound (+)

Extremity

Look
Deformitas (-), shortening (-), lengthening (-), swelling
(+)
Feel
CRT <2, warm, pulsation of a. Dorsalis pedis sinistra
and dextra (+), Sensoris (+), crepitation (-)
Move
Normal

Workup

Chest X-ray
CBC
Complete urine count

Asessment

Ca mammae sinistra
Dyspnoe e.c metastasis pleura
Limfodenitis

Management

O2 4 lpm
IVFD RL 10 tpm
If leucocytosis Ceftriaxon 2x1gr iv

Picture

Case 3

Identity

Name : Mr. TB
Age
: 22 y.o
Sex
: Male
Address : Camplong

History Taking

Chief Complaint: Burn wound

Present

Complaint: Patient presented w/ painful

burn wound existed from a day ago, resulted from
falling on top of a flaming cooking stone stove
while squatting in front of it. Toothpaste was
applied on his burn wound before he was
admitted at RS Naibonat.

Physical Examination

Primary Survey

A: Clear
B: spontaneous breathing with RR of 20
C: Pulse rate: 88
D: Alert (GCS: E4V5M6)

Secondary Survey

Hair
: Black, Allopecia (-)
Eyes
:
Conjungtiva : Anemic (-/-)
Sclera
: Icteric (-/-)
Ears : Normal
Nose : Normal
Mouth : Normal
Neck : Lymphadenopathy (-)

Physical Examination

PULMO
Inspection:

symmetrical chest expansion

Palpation : Vocal fremitus (d=s), mass (-),
crepitation (-)
Percussion: sonor (+/+)
Auscultation : Vesiculer (+/+),Ronchi (-/-),
Wheezing (-/-)

COR
S1/2

single, murmur (-), gallop (-)

Physical Examination

ABDOMEN
Inspection

: Flat, suitable with breathing

Auscultation : normal peristaltic sound
Palpation : Tenderness (-)
Percussion : Tympanic sound

Local status

Location; face, neck, distal 2/3 of the left arm,

medial 1/3 of right upper arm.

Lab Results

DL
WBC: 24,64
Lymph: 1,84
Mono:1,48
Eo:0,52
Baso: 0,03
Neut:20,77
RBC13,56
HGB 14,9
HCT 43,6
MCV 78,4
MCH 26,8
MCHC 34,2
PLT 206

UL
BJ: 1.020
pH 6,0
Lekosit +3
Nitrit (-)
Glukosa N
Protein N
Urobilinogen N
Keton (-)
Bilirubin (-)
Eritrosit +3

Sedimen
Lekosit penuh
Eritrosit 15-20/lp
Epitel 15-20/lp
Silinder (-)
Kristal (-)
Bakteri (-)

Lab Results

Ureum 16,1
Creatinin 0,3
GDS 133
Na 137
K 4,2
Cl 104

Planning

Plasma Albumin

Assessment

Grade 2 burns with 17% body area

involvement

Planning Therapy

Wound Toilet
Burnazine zalf
Inj ATS 1 amp IM
IVFD RL 20 tpm
Inj. Omeprazole 1 amp IV
Inj. Cefotaxime 2x1 gr IV