Morning report

21/02/2020
Name:
DM Albert DM Elvin DM Vira
Konsulen: dr. Alders, Sp. B
 Identity of patient 4
• Name : Tn. DS
• Sex : Male
• Age : 78 years old
• No MR :

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 Anamnesis
• Chief complain : can’t urinate since 1 day a go
• History of disease:
patients present with complaints of not being
able to urinate since 1 day ago and there is blood
on the catheter used by patients. there has been
an enlargement of the scrotum that has occurred
since the end of December 2019. The patient was
examined at a poly surgery in december 2019 and
a catheter was placed. vomit (-). Last defecate this
morning, hard consistency, like goat feces. Right
now he still fell pain at the scrotum

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• Past Diseases story :
- 2012: Herniotomy
• History of medicine: -
 Vital Sign
• Blood Preasure : 140/80
• Heart Rate : 87 times per minute
• Respiratory Rate : 22 times per minute
• Temperature : 36,3˚C
• SpO2 : 99%
 Physical examination
General state : Moderate illness
GCS : E4V5M6
Head : Normocephal
Eye : anemic conjungtive(-/-), icteric sclera(-/-)
Ear : otorhagia (-/-)
Nose : Rhinorea (-/-),
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultation : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
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Abdomen: belum
• Inspection : flat, symetric,
• Ausculation : bowel sound (+) normal
• Palpation : Supel, organomegaly (-)
• Percussion : Tympanic
extremities:
• Warm
• edema (-/-)
• CRT < 2 sec

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 Assesment
Hernia inguinalis dextra

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 Planning
• Tranecsamic acid Inj.
• Ketorolac injection
• Pro Herniotmy

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 Identity of patient 4
• Name : Mr. MDB
• Sex : Male
• Age : 19 years old
• No MR :528264
• Came to ER : 20.50 WITA

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 Anamnesis (11.15 WITA)

• Main complain : Pain on the hand and right foot

• History of disease:
patient, male 19 years old, referral from SK Lerik hospital
with diagnosis of open fracture in PIP 4 right hand, right
wrist dislocation and vulnus amputatum on Digiti 2 right
pedis. the patient had a motorcycle accident since noon,
when he fell the patient fell to the right and was dragged
along the road. Loss of consciousness (-) Nausea (-),
Vomit (-). Right now, he still feel pain at the wound. It
worsen with movement and ease with rest.
• Past Diseases story : -
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 Primary survey
• A : clear, snoring (-), gurgling (-), stridor (-)
• B : spontan, RR 20x/minute, SpO2 : 100%
• C : BP 110/60 mmHg, CRT<2sec, HR
67x/minutes
• D : Alert, GCS: E4V5M6
• E : there are multiple excoriation on his right
arm, and left arm. Laceration and swelling on
right back hand, swelling on right arm, vulnus
amputatum on digiti 2 pedis.
 Secondary survey
General state : Moderate illness
GCS : E4V5M6
Head : Normocephal, bruise (-)
Eye : anemic conjungtive(-/-), icteric sclera(-/-), bruise (-/-)
Ear : otorhagia (-/-)
Nose : Rhinorea (-/-), blood (-/-)
Lip : bleeding (+) , swelling (+), wound (+)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
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Abdomen:
• Inspection : flat, symetric,
• Ausculation : bowel sound (+) normal
• Palpation : Supel, organomegaly (-)
• Percussion : Tympanic
Extremities:
• Warm and cianotic (-)
• edema (-/-)
• CRT < 2 sec

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 Local status

• Inspection : multiple vulnus

axcoriatum on left forearm
diameters 5cm, and right
arm. Vulnus Laceratum on
right backhand and swelling
on right hand. Open fracture
on PIP 4.
• Palpation : tenderness (+),
warm (+),
• ROM : Limited
 Local Status
• Inspection : vulnum
amputatum on right
digiti pedis 2, vulnum
laceratum on right
digiti pedis 3,4,5
• Palpation : warm (+),
• ROM : Limited
X-Ray
 assesment
• Fracture PIP 4 right hand + dislocation on
wrist joint
• Vulnus amputatum on right digiti pedis 2
• Vulnus laceratum on back hand and right
digiti pedis 3,4,5
• Vulnus excoriation on left arm and right
arm

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 Planning
• IGD
– Spalak
– wound care
– anti-tetanus injection

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THANK YOU

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