Morning Report

25th of September 2015

Co-ast : Dwi Permana Putra
Doctor in charge: dr. Putu

Identity

Name : Mr. Djufuk

Sex : Male
Age : 34 y.o
Religion : Budhist
Occupation : company employee as goods
delivery
Address : Gg. Teratai
MR No. : 085478
Hospitalized : 25th of September 2015, at
03.40 pm

Primary Survey
Airway :
Look : agitation (-), sianotic (-), retraction (-),
muscle used on breathing (-)
Listen : snoring (-), gurgling (-), crowing
sound (-) & stridor (-)
Feel : Trachea deviation(-)
Breathing : respiration rate28x/menit, type of
breathing torachoabdominal, Thorax
symmetrically expansion (+), chest pain while
breathing (+), percussion sonor (+), Lung sound
vesicular (+/+)

 Circulation : bleeding (-), pulse

78x/min regular, pale of the skin (-),
blood pressure 90/80 mmHg
Disability : compos mentis, pupil
isochor 3mm/3mm, direct light reflex
(+), indirect light reflex (+)
Environment : administered of ringer
lactate fluid about 20 drops/minutes

 Chief complaint
Pain on the central chest

History of present illnesses

Patient came to the emergency department at
3.40 pm was due to pain on his middle chest
since 15 minutes before arrival. The pain felt
continously especially when he was breathing
and felt breathless
Before that, the patient experienced with
accident by crashed with a motorcycle ahead
of him. After crashed, his chest was hit by
handle of motorcycle and his body slammed to
the front also his head landed into the road.
His helmet was released after all

 Patient recognized, suddenly his sight for

a minute before he got up and was
helped by people around him. Headache
(-), dizziness (+), nausea (-), vomitting
(-), convulsion (-), secretion from nose
and ears (-). Others history of illnesses
Asthma (-), Diabetes Melitus (-),
Hipertension (-), uric acid (-), cholesterol
(-). History of surgery (-), trauma (-)

 Allergy : asthma (-), allergic on

medications (-)
Medication :there was no medication
after injury
Past Illness: trauma (-), surgery (-)
Last Meal : Event
:-

Physical Examination
Vital Signs

General conditions : felt pain

Awareness
: Compos Mentis
Blood Pressure : 90/80 mmHg
Pulse
: 78x/min
Respiratory rate : 28x/min
Temperature : 36,4oC

Head to Toe Examination

Head & maxilofacial
Inspection : laceration (-), bleeding (-), contusio (-), fracture
(-), hematoma (+) at regio os frontalis dextra, bleeding from
teeth of 2nd premollar (+)
Palpate : crepitation (-), tenderness (+) a/r os frontalis dextra

Eye: bleeding (-), penetrating injury (-), softlense used

(-), optic nerve damage (-), anemia (-), icteric (-)
NET : Bleeding (-), unsteady teeth (+) a/r central
incicis inferior, dentures used (-), battle sign (-)
Neck : hyperemia (-), deformity (-), swollen (-),
subcutaneous emphysema (-), trachea deviation(-),
muscle use breathing assistance (-),tenderness (-)

 Chest : symmetric (-), deformity (-), hyperemia (+)

et causa vulnus excoriation et regio manubrium
sternum, SIC 2 midclavikula dextra line, SIC 6
midaxilla dextra line, scar (-), muscle use breathing
assistance (-),
Cor
Inspection : ictus cordis is invisible
Palpasi : Ictus cordis feel at SIC 4 midclavikula sinistra line
Perkusi : upper site SIC 2 Midklavikulas sinistra line, right
site at SIC 4 Parasternal sinistra line, left site jantung SIC
4 Midclakula sinistra line
Auscultation : Murmur (-), Gallop (-)

 Paru
Inspection : expansion of chest (+),
breathing pattern thoracoabdominal, scar
(-), muscle use breathing assistance (-)
Palpation : subcutaneous emphysema (-),
tenderness (-), crepitation (-)
Percussion : sonor (+)
Auscultation : vesicular (+/+), crackles
(-), wheezing (-)

 Abdominal :
Inspection
Palpation :
Percussion
Auskultasi:

: flat , scar (-), hyperemic (-), tumor (-)

tenderness(-), hepar dan lien (-), tumor (-)
: tympanic (+)
metallic sound (-) normal

Genital : unperformed
Anus : unperformed
Extremities :oedema (-), CRT < 2, cyanotic (-),
vulnus excoriation et regio cruris dextra, vulnus
laceratum et regio digiti 3 pedis dextra size
length 3 cm, width 1 cm, depth 1 cm

Resume
Patient came to the emergency
department at 3.40 pm was due to pain on
his middle chest since 15 minutes before
arrival. The pain felt continously especially
when he was breathing and felt breathless.
The patient experienced with accident by
crashed with a motorcycle ahead of him.
His chest was hit by handle of motorcycle
and his body slammed to the front also his
head landed into the road.

 Patient recognized, suddenly his sight for a

minute before he got up and was helped by
people around him. dizziness (+), Others
history of illnesses (-)
Physical examination
General conditions : felt pain
Awareness : Compos Mentis
Blood Pressure : 90/80 mmHg
Pulse : 78x/min
Respiratory rate : 28x/min
Temperature: 36,4oC

 Local Status
Chest : symmetric (-), deformity (-), hyperemia
(+) et causa vulnus excoriation et regio
manubrium sternum, SIC 2 midclavikula dextra
line, SIC 6 midaxilla dextra line, scar (-),
muscle use breathing assistance (-)
Extremities :oedema (-), CRT < 2, cyanotic
(-), vulnus excoriation et regio cruris dextra,
vulnus laceratum et regio digiti 3 pedis dextra
size length 3 cm, width 1 cm, depth 1 cm

Working Diagnosis
Traumatic thoracic blunt

Workup

Diagnosis
Traumatic thoracic blunt with
multiple vulnus excorations
Vulnus laceratum a/r digiti 3 pedis
sinistra

Differential Diagnosed
Sternum fracture
Ribs fracture

Treatment
Ringer Lactate 20 tpm infusion
Local anesthesia by using 0,5-1 ml
lidocain at surrounding the wound
Sutured the wound at regio digity 3
pedis sinistra by using silkam sutures
3/0
Inj. Ketorolac 3 x 30 mg (k/p)
Inj. Asam Tranexamat 2 x 50 mg

Thank you

Identity

Name: Mr. Teddy Layardi

Sex : Male
Age : 26 y.o
Religion : Budhist
Occupation : company employee as
engineer
Address : Jln. Nurul Huda Gg. SGO No. 75,
Ketapang
Hospitalized : 25th of September 2015, at
08.30 pm

 Chief complaint
Enlargement on the right testis

History of present illness

Patient came to the emergency department at
8.30 pm was due to enlargement on the right
testicle since a week ago. the complaint was
accompanied by tenderness and was not relieved
by medications. The pain also felt up to both of
his waists. 9 days ago the patient had
experienced with sore throat but it has already
gone. Another complaints such as fever (+) up
and down since a week ago, headache (+),
malaise (+), nausea (-), vomitting (-), eat/drink
(+), urination (+), history of mumps (-), allergy (-),
Hipertension (-), DM (-)

Past history of illness

-

History of habituation
Consumption of alcohol (-), smoking
(-)

History of social & economy

The patient work in private company
as a engineer at the moment

Family history
There is no similar complaints in his
family

Physical Examination
Vital Signs

General conditions : felt pain looks

relax
Awareness
: Compos Mentis
Blood Pressure : 120/80 mmHg
Pulse
: 96x/min
Respiratory rate : 28x/min
Temperature : 36,7oC

Pemeriksaan Head to Toe

Head
: Normocephaly
Eye
: anemic conjunctiva (-),
icteric (-)
NET
: Septum deviation (-),
secretions (-), tonsil T1/T1 (+),
pharyngeal hyperemia (-)
Neck
: trachea
deviation(-),tenderness (-)

 Chest :
Cor
Inspection : ictus cordis is invisible
Palpasi : Ictus cordis feel at SIC 4
midclavikula sinistra line
Pecussion : upper site SIC 2 Midklavikulas
sinistra line, right site at SIC 4 Parasternal
sinistra line, left site jantung SIC 4
Midclakula sinistra line
Auscultation : Murmur (-), Gallop (-)

 Paru
Inspection : expansion of chest (+),
breathing pattern thoracoabdominal, scar
(-), muscle use breathing assistance (-)
Palpation : subcutaneous emphysema (-),
tenderness (-), crepitation (-)
Percussion : sonor (+)
Auscultation : vesicular (+/+), crackles
(-), wheezing (-)

 Abdominal :
Inspection
Palpation :
Percussion
Auskultasi:

: flat , scar (-), hyperemic (-), tumor (-)

tenderness(-), hepar dan lien (-), tumor (-)
: tympanic (+)
metallic sound (-) normal

Genital : right scrotum looks hyperemia (+),

warm(+), tenderness (+), left scrotum looks
normal, penis looks normal, phrens sign (-)
Anus : unperformed
Extremities :oedema (-), CRT < 2, cyanotic (-)

Resume
Patient has experienced with enlargement
on the right testicle since a week ago and
accompanied by tenderness. The pain also
felt up to both of his waists
9 days ago the patient had experienced
with sore throat but it has already gone
fever (+) up and down since a week ago,
headache (+), malaise (+), eat/drink (+),
urination (+), history of mumps (-)

 Physical examination
Vital Signs
:
General conditions : felt pain looks
relax
Awareness
: Compos Mentis
Blood Pressure : 120/80 mmHg
Pulse
: 96x/min
Respiratory rate : 28x/min
Temperature : 36,7oC

Localized status
Genital
: right scrotum looks
hyperemia (+), warm(+), tenderness
(+), left scrotum looks normal, penis
looks normal, phrens sign (-)

Working Diagnosis
Orchitis dextra dd. Testicular tortion

Further examination
Scrotal USG
Scrotum kiri : tampak testis kiri besar bentuk baik,
parenkim homogeny tak tampak mass/fluid
collection
Scrotum kanan : tampak testis kanan membesar (
5 x 3,38 x 2,5 cm) parenkimecho hipoechoik
homogeny (swollen), tampak fluid collection
minimal epididimis tak menebal, tak tampak mass
Vaskularisasi parenkim testis kanan dan kiri baik
Kesan : Sugestif orchitis kanan dengan
hidocele kanan minimal

Diagnosis
Orchitis dextra with minimal
hydrochele

Differential Diagnosed
Testicular tortion

Treatment

Ringer Lactate 20 tpm infusion

Inj. Ketorolac 3 x 30 mg
Inj. Ranitidine 2 x 25 mg
Ciprofloxacin 2 x 200 mg infusion
Paracetamol tablet 3 x 500 mg (if
needed)

Thank you