Morning report

28 Oktober 2015

Patient identity (1)

Name
: Miss N
Sex
: Female
Age
: 16 years old
Address
: Gg. Budiman

Chief complaint
Headache

Present illness history

Patient come to the hospital with complaint of
headache approximately 90 minutes before
enter emergency room. This complaint is felt
after she got into an accident. Her motorcycle
hit another vehicle and then she fell down to
left side and her head hit the ground.
According to her, after the accident she was
fainted for about 3 minutes. Nausea (+),
vomiting (-), visual disturbance (-). There is no
bleeding from nose or ears.

Past medical history

History of hypertension (-)
History of DM (-)

Physical examination
Vital sign
GCS
: 15 (Compos Mentis)
Blood pressure : 120/70
Hate rate
: 92 x / min
Respiratory rate : 20 x / min
Temperature
: 36,5C

Physical examination
Head: normosefali
Eyes: anemic conjunctiva (-/-), icteric
sclera (-/-),
Pulmonary: Normochest, breath sounds
basic: Vesicular (-/-), Wz (- / -), Rh (- / -)
Heart: Regular S1S2, Galoop (-), Murmur (-)
Abdomen: flat, nontender, turgor (+),
bowel sounds (+) normal
Extremities: CRT <2

Localized Status
vulnus excoriatum 4 cm x 3 cm a/r
antebrachii sinistra
vulnus excoriatum 2 cm x 1 cm a/r
pedis dextra
vulnus excoriatum 2 cm x 1 cm a/r
pedis sinistra
Contusio a/r temporal sinistra

X-Ray

Diagnosis
Mild brain injury

Therapy
Head up 30
Oxygen 3 lpm
NaCl 20 dpm
Piracetam 1 amp
Citicolin 1 amp
Ketorolac 1 amp
Ranitidin 1 amp

Prognosis
Ad vitam
: bonam
Ad functionam : bonam
Ad sanactionam : bonam

THANK YOU