1

MORNING REPORT
DECEMBER 23RD, 2015
Surgery clerkship
Fadilla Safira
Fariza Andriyawan

M. SUTOMO HOSPITAL

Patient Identity #1
2

Name
: Mr. J
Age
: 45 years old
Sex
: Male
Religion
: Islam
Address
: Parit Keramat
Admission date
: December 22nd ,
2015
Time
: 1.45 pm

History of Present Illness

3

Chief complain:
Pain in the right leg

Present illness history:

Patient present with pain in the right leg since

15 minutes before admitted to hospital. He
had an accident when he was breaking down
a wall. Then he slipped and fell down because
of the slippery sandals. He fell down with his
right leg as the pedestal then slightly the
materials of the wall hit his right leg. Then,
according to patient his right leg was difficult
to be moved because of the pain.

He said that the materials of the wall

just hit his right leg, no other part of
his body was involved in that accident.
No materials of the wall hit his head
and his head was safe from any bumps.
He remembers every single moments
when
the
accident
happened.
Dizziness, headache, nausea, fainting
and vomit didnt happen to the patient

Past Medical History

6

Past Illness
-Same complain (-)
-Other illness (-)
According to the patient he had an
Appendectomy two years ago.

ABCDE
7

Airway: clear
Breathing: Symmetrical shape of the left
and right

chest, vesicular breath sounds

(+/+), Rh (-/-), Wh (-/-)

Circulation:
a. BP 130/70 mmHg
b. HR 76 times/minute
c. RR 24 times/minute
d. Temp 36,8 C

ABCDE
8

Disability
GCS: (E4 M6 V5)
Left and right
diameter 3 mm

pupil

round,

isokhor,

Localized status
9

a/r cruris dextra

Look
: Edem (+)
Feel
: Warm, tenderness (+),
sensibility (+),
pain of pressure
(+), CRT <2,
crepitation
(-)
Movement: ROM Active limited pain

Laboratory test
10

Hb
: 12,6 gr%
Leukocytes
: 10.300/mm3
Platelets : 217.000/mm3
Hematocrit
: 36 vol%
BT
: 2.30 minutes
CT
: 5.30 minutes

A/r Cruris Dextra

11

Cruris Dextra
12

Diagnosis
13

Fracture os fibula dextra

Therapy
14

Consult to dr. Romidon, Sp.B

IVFD Ringer Lactate 20 dpm
Cast splintage a/r cruris dextra
Ketorolac injection (IV) 1 amp/8 hours
Ranitidin injection (IV) 1amp/ 12 hours
Ceftriaxone 2gr (IV) (Extra)

Prognosis
15

Ad vitam
Ad functionam
Ad sanactionam

: bonam
: bonam
: bonam

16

THANK YOU

PATIENT IDENTITY#2
17

Name
Sex
Age
Religion
Address
Pontianak
Admission
Time

: Mrs. SH
: Female
: 40 years old
: Islam
: Jl. Danau Sentarum
: December 22nd , 2015
: 10.30 pm

History of Present Illness

18

Chief complain:
A bump and pain in the head
Present illness history:

Patient present with a bump and in the head since 15

minutes before admitted to hospital. She had an
accident when she walked on the street. Suddenly,
she was hit from behind by a motorcycle with the
speed of 30km/hour and then falling to the right
but still on the side of the road. She was thrown to
the ground. Fainting (-), headache (+), nausea (+),
dizziness (+), vomiting (-), amnesia post accident
(-).

Past Medical History

19

Past Illness
-Same complain (-)
-Other illness :
1. Hypertension grade I status uncontrolled
(+)
2. Diabetes mellitus (-)

ABCDE
20

Airway: clear
Breathing: Symmetrical shape of the left
and right

chest, vesicular breath sounds

(+/+), Rh (-/-), Wh (-/-)

Circulation:
a. BP 150/90 mmHg
b. HR 76 times/minute
c. RR 20 times/minute
d. Temp 36,5 C

ABCDE
21

Disability
GCS: (E4 M6 V5)
Left and right pupil round, isokor, diameter
3 mm

Localized status
22

a/r os frontalis
Look
: Deformity (+), hematoma (+),
edem (+)
Feel
: Warm, tenderness (+),
sensibility (+),
pain of pressure (+), fluctuation
(+)
Movement: ROM Active limited pain

Head
23

Laboratory test
24

Hb
: 11,3 gr%
Leucocytes
: 11.400/mm3
Erythrocytes : 4,61 X 106 /mm3
Platelets : 306.000/mm3
Hematocrit
: 32 vol%

25

Diagnosis
26

Hematoma a/r os temporoparietalis e.c

trauma

Therapy
27

Consult to dr. Romidon, Sp.B

Oxygen 2 lpm
IVFD NaCl 20 dpm
Ketorolac injection (IV) 1 amp/ 8 hours
Ranitidin injection (IV) 1 amp/12 hours
Cefotaxim 1 gr/12 hours

Observation
28

Time

GCS

BP

HR

RR

Temper
ature

10.30 pm

E4M6V
5

150/90
mmHg

76
times/minut
e

20
times/minute

36,5oC

11.30 pm

E4M6V
5

150/80
mmHg

74
times/minut
e

22
times/minute

36,5oC

00.30 am

E4M6V
5

140/80
mmHg

76
times/minut
e

20
times/minute

36,4oC

140/80
mmHg

82
times/minut
e

20
times/minute

36,6oC

01.30 am

E4M6V
5

Prognosis
29

Ad vitam
Ad functionam
Ad sanactionam

: bonam
: bonam
: bonam

30

Thank you