MORNING REPORT

IDENTITY
Name : Mr. Y
Age : 15 years old
Sex : Male
Address :
Admission : September, 01th 2017
Doctor in charge : dr. H. Syamsul Rijal, Sp. B
 HISTORY TAKING
Chief complain :
Left abdominal pain
Anamnesis :

The patients come to hospital with uleft abdominal pain since 4 hour ago after a traffic
accident
Mecanism of trauma :
The patient as the biker wearing a helmet with moderate speed was hit by a car from behind
There were history of unconscious, vomiting (-), bleeding nose (-), bleeding ear (-), and
bleeding mouth (-). There was no previous medication
 PRIMARY SURVEY
A
Clear

RR 18x/min regular, spontaneous B

thoracoabdominal type, symmetrical
C BP 110/70 mmHg
Pulse = 96x/min, regular, strong, CRT < 2 minutes

D
GCS 15 (E4M6V5), pupil isochor

E T = 38.20 C (axillary)
 SECONDARY SURVEY
Head : Normally
Face : Normally
Eyes : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
Thoraks : Normally
Lower limb : Normally
 LOKALIS STATE
Abdomen :
Inspection : flat, distended (-), wound (-)
Palpation : tenderness (+) left hipiokondrium region, epigastric region and left lumbal region,
Massa (-), defans muscular (-)
Perkusi : tap pain (+) left hipiokondrium region, epigastric region and left lumbal region
Auskultation : Tympani (+)

Left upper extremities :

inspeksi : Lacerated wound at middle fingger (size 2x1,5x0,5 cm), deformity (+), swelling (-),
hematoma (-)
Palpasi : pain (+)
ROM : Aktive pasive interphalangs joint limited movement due to pain
NVD : sensitivity (+), a. Radialis pulse (+), CTR < 2 second
 PLAN OF DIAGNOSTIC

Complete Blood Count

USG
 DIAGNOSIS

Abdominal Blunt trauma

 MANAGEMENT
IVFD

Antibiotics

Analgetics

H2 reseptor antagonis

Consult general surgeon

 Thank You

BAGIAN ILMU
Luphyta Nimandana
BEDAH