Morning Report

Departement of Surgery
Wednesday, 14th August 2019
L30
 LIST OF NEW PATIENTS
Trauma Non Trauma
1. Tn Topo : Vulnus appertum 1. Ny. Parti : Dm Gangren
digiti 4,5 pedis sinistra 2. Tn.Junda : HIL
2. An Putri : EDH
3. Tn.Nurcholis : CKR
 Identity
• Name : An P
• Age : 6 years old
• Address : Nglebur, Kedungprin,
Lamongan
• Admitted : August 14 2019
 Anamnesis
• Chief complain : Headache
• Present history :
• patients came to the emergency room with complaints of
headache since 8 hours after the accident. after the accident
the patient is still conscious. this time the patient also
vomited 4 times after the accident. complaints of blood
coming out of the ear and nose are denied. complaints of
dyspnea are denied, complaints of tightness are denied.
• MOI :
• initially the patient wanted to cross but when it had crossed
and was pulled over the patient was smashed from the left by
a pickup truck.
Primary Survey

A : clear, gargling (-), snoring (-), speak fluently (+), obstruction risk (-)

B : spontaneous, RR 26x/min, ves/ves, Rh -/-, Wh -/-, SaO2 94%

without O2 support

C : WDR, CRT < 2” N 90x/min TD 109/68 mmHg

D: GCS: 456, lateralisation:-, PBI 3mm/3mm, RC +/+

E : temp 36.9 C, lesions et regio frontalis (+)

 Secondary survey
GCS 456
K/L: a -/ I -/c -/d -
Tho: sim, ret -/-, lesion on frontalis (+)
P: ves/ves; rh -/-, wh -/-,
C: S1S2 single, murmur -, gallop -
Abd: soepel, met -, BU + N, Liver WNL, spleen WNL, defans
muscular (-), tenderness (-)
Ext: aie - , pitting edema -/-
St. lokalis R/ frontalis :
• L: vulnus ekskoriasi et reg frontalis S 3X2 cm,
active bleeding -, edema -, vulnus appertum et
reg parietal S 3x2 cm, active bleeding -
• F: NT (+)
• M:-
Foto Klinis
• Planning Dx:
• CT scan
Hasil Ct Scan Kepala
Eritrosit 4.76 ( 3.80 - 5.30 )
Hemoglobin 10.7 ( 14.0 - 18.0 )
Laju Endap Darah 1 34 ( 0 - 1 )
Laju Endap Darah 2 55 ( 1 - 5 )
Limposit 2.9 ( 25.0 - 33.0 )
Basofil 0.1 ( 0.0 - 1.0 )
Eosinopil 0.3 ( 1.0 - 2.0 )
Hematokrit 34.2 ( 40.0 - 54.0 )
Lekosit 15.5 ( 4.0 - 11.0 )
MCH 22.50 ( 28.00 - 36.00 )
MCHC 31.30 ( 31.00 - 37.00 )
MCV 71.80 ( 87.00 - 100.00 )
Monosit 2.9 ( 3.0 - 7.0 )
MPV 6 ( 5 - 10 )
Neutropil 93.8 ( 49.0 - 67.0 )
RDW 12 ( 10 - 16 )
Trombosit 313 ( 150 - 450 )
Hbs Ag ( Negatif )
PT ( 10,3 - 16,3 )
APTT ( 24,2 - 38,2 )
metode 1 ( Non Reaktif )
 Assessment
• EDH
 Therapy
• Hospitalized
• Inf. RL 1200cc/24 jam
• Inj. Ranitidin 2x24 mg
• Inj. Ondancentron 4 mg prn
• Inj. Citicoline 3x125 mg
• Inj. Piracetam 4x1 gr
• Inj Santagesik 3x200 mg