Morning Report

Monday, 21 November 2016

Siska Sarwana, S.Ked
Rogayah, S.Ked

Identify Patien
Name
: elisa
Age
: 18 years old
Gender : a woman

Chief Complain
Laceration on the chin
Anamnesis : the patients was
reffered to IGD RSMP after a traffic
accident 20 minutes before. She
was hit by a motorcycle with a
collapsed
potition.
Nausea
(-),
vomiting (-), fainting (-)

Primary Survey
General state : moderately ill, GCS
15
Vital Signs :
Blood Preasure : 110/80 mmHg
Pulse Rate : 88x/m
Respiratory Rate : 22x/m
Temperature : 36.6C

Secondary Survey
Head : appears torn on the frenulum
3x2, abrasions on the chin 2x1 cm
Thorax : ves (+) normal, rhonki (-),
wheezing (-), murmur (-), gallop (-),
pain (-)
Abdomen : no abnormality
Extremity : abrasions on knees
1x0.5cm and soles of the feet 1x1
cm

Local Status
Look : appears torn on the frenulum
3x2, abrasions on the chin 2x1 cm,
abrasions on knees 1x0.5cm and
soles of the feet 1x1 cm
Feel : pain (+)

Diagnosis
Vulnus laceratum on frenulum,
vulnus excoriatum on regio mentalis,
genus dextra and sinistra, also pedis
sinistra

Treatment
Wound Toilet
Hecting : 8 stitches