MORNING

REPORT
September 14th, 2023
Identity

● Name : Mr.Rio
● Age : 40 th
● Weight : 70kg
● Gender : Male
● Address : Batu
● Arrival Date : 15/9/2023
● Patient Type : Trauma
 PRIMARY SURVEY

Incident date: 15/9/2023 at 00.00 WIB

Arrival date: 15/9/2023 at 01.30 WIB

Anamnesis:
Main Complaint : loss of consciousness & headache after being beaten, stepped on
and kicked
RPS : Patient came to the ER with decreased consciousness and pain in the head
VAS 7-8 after being beaten, stepped on and kicked. He still drunken by alcohol, had
fainted, headache (+), nausea, vomiting (-), retrograde amnesia (+), otorhea (-),
rhinorhea (-)
MOI : loss of consciousness & headache after being beaten, stepped on and kicked
 PRIMARY SURVEY
Examination Initial Diagnosis Action
Airway: Partial Obstruction Head tilt Chin lift
Snoring (+), gargling (-), stridor (-)
Breathing: Breathing spontaneusly O2 NRBM 10 lpm
Look: symmetrical chest wall movement (+), lesion (+),
deformity (-)
Feel: the patient breathes spontaneously, no additional
breath sounds, rib crepitations (+), dyspnea (-)
RR: 15x/minute
SpO2: 98% on RA
Circulation: - Cairan Maintance Holliday
BP : 135/79 mmHg Segar (70 Kg)
HR: 94x/m (100ml x 10kg) + (50ml x
CRT <2s, warm dry red acral 10kg) + (20ml x 50kg) =
Active bleeding (-) 2500 ml/24 jam
Disability : Mild TBI (GCS 346) dd - GCS observation
GCS 346 Somnolens Alcohol intoxication
Isochor pupil diameter 3mm/3mm, Light reflex direct and
indirect +/+, cornea reflex +/+, move the eyeball in all
directions (+)
 PRIMARY SURVEY
Examination Initial Diagnosis Action
Exposure: Mild TBI (GCS 346) - CXR AP
Warm red dry acral (+/+) CRT<2s, / Contusio muskulorum - Head CT scan non
Temperature: 36,3 ⁰ C, Thorax sups fracture costae contrast
Localist status Contusio head - IVFD RL 30 tpm
Temporalis S Region - Inj. Ranitidine
Look: vulnus laceratum ±1x3cm with base of dermis and 2x50mg
irregular borders, edema (+), hematoma (+), active bleeding - Inj. Ketorolac
(+), 3x30mg
Feel: tenderness (+), crepitus (-) - Inj. Citicolin 250 mg
Facial Region - Inj. Piracetam 3 gr
Look: multiple vulnus abrasion et contusio, hematoma (+),
active bleeding (-)
Feel: tenderness (-), crepitus (-)
Thoracic Region
Look: multiple hematoma, erythema (+)
Feel: tenderness (+), crepitus (+)
Back Region (Logroll)
Look: multiple hematoma and contusion, erythema (+)
Feel: tenderness (-), crepitus (-)
 SECONDARY SURVEY

GENERALIST STATUS

GCS: 346 somnolens

BP : 183/89 mmHg
HR: 65x/minute
RR: 19x/minute
T: 36,5 C
SpO2 : 99% on RA
 SECONDARY SURVEY
ANAMNESIS
Symptom: Headache slightly better vas 6-7
although pain in other region still persist
Allergy : -
Medication: drunk (alcohol)
Past illness : -
Last meal : 00.00 (15/9/2023)
Event : loss of consciousness & headache
after being beaten, stepped on and kicked
while drunked
 PHYSICAL
EXAMINATION
THORAX :
Cor:
Inspection: ictus cordis invisible, lesion (+),
HEAD/NECK:
hematome (+)
Palpation: ictus cordis palpable at ICS 5 MCL S,
Head
crepitation at costae 5 dextra anterior
Eyes: Anemic conjunctiva (-/-), icteric sclera (-),
Percussion: Right heart border at PSL D ICS 4,
Isochor pupil diameter 3mm/3mm, Light reflex direct
heart border Left at MCL S ICS 5
and indirect +/+
Auscultation: S1 S2 single, regular, murmur (-),
Ears : bloody Otorea (-/-)
gallop (-)
Nose : epistaksis (-/-)
Pulmo:
Neck :
Inspection: normal chest wall shape, retraction
Inspection: tracheal deviation (-)
(-), looks symmetrical (+/+)
Palpation: tenderness (-), enlarged lymph nodes (-)
Palpation: symmetrical D/S chest wall
Auscultation : Bruits (-)
movement
Percussion: sonor all lung fields
Auscultation: Ves/Ves, rh (-/-), wh (-/-)
 PHYSICAL
EXAMINATION
Localist status

Temporalis S Region
Look: vulnus laceratum ±1x3cm with base of
dermis and irregular borders, edema (+),
Abdomen:
hematoma (+), active bleeding (+),
Inspection : Flat, injury (-), lesion (+)
Feel: tenderness (+), crepitus (-)
Auscultation : Bowel sound (+) 10x/minute
Facial Region
Percussion : Timpany all abdomen fields
Look: multiple vulnus abrasion et contusio,
Palpation : Flat, soft, superficial tenderness (-),
hematoma (+), active bleeding (-)
deep tenderness (-)
Feel: tenderness (-), crepitus (-)
Thoracic Region
Pelvic: Stable
Look: multiple hematoma, erythema (+)
Feel: tenderness (+), crepitus (+) at costae 5
Extremities : Dry warm acral, CRT <2 s
dextra anterior
Back Region (Logroll)
Look: multiple hematoma and contusion,
erythema (+)
Feel: tenderness (-), crepitus (-)
CLINICAL PICTURE
CLINICAL PICTURE
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning Planning
Diagnosis Therapy &
Monitoring
Anamnesis: • Mild TBI (GCS 346) • Xray - Wound care
Main Complaint : loss of consciousness & • Susp closed fracture thorax - IVFD RL 20 tpm
headache after being beaten, stepped on costae • CT head - Inj. Ketorolac
and kicked • Blunt thoraco- non 30mg
- still drunken by alcohol abdominal trauma contrast - Inj. Citicolin 250
- fainted (+), headache (+), nausea, vomiting • USG mg
(-), retrograde amnesia (+), otorhea (-), abdomen - Inj. Piracetam 3
rhinorhea (-) • CBC gr
GCS: 346 somnolens - Observe clinical
BP : 183/89 mmHg features/ICP
HR: 65x/minute 2x24hours
RR: 19x/minute
T: 36,5 C
SpO2 : 99% on RA
 Problem list Initial Diagnosis Planning Planning Therapy
Diagnosis & Monitoring

Localist status • Mild TBI (GCS 346) • Xray thorax - Wound care
Temporalis S Region • Susp closed • CT head - IVFD RL 20 tpm
Look: vulnus laceratum ±1x3cm with base of fracture costae non - Inj. Ketorolac
dermis and irregular borders, edema (+), • Blunt thoraco- contrast 30mg
hematoma (+), active bleeding (+), abdominal trauma • USG - Inj. Citicolin 250
Feel: tenderness (+), crepitus (-) abdomen mg
Facial Region • CBC - Inj. Piracetam 3
Look: multiple vulnus abrasion et contusio, gr
hematoma (+), active bleeding (-) - Observe clinical
Feel: tenderness (-), crepitus (-) features/ICP
Thoracic Region 2x24hours
Look: multiple hematoma, erythema (+)
Feel: tenderness (+), crepitus (+) at costae 5
dextra anterior
Back Region (Logroll)
Look: multiple hematoma and contusion,
erythema (+)
Feel: tenderness (-), crepitus (-)
 CBC (14/9/2023)
HGB 15.8 g/dL
WBC 8.7 10^3/uL
Lab LED 10 mm/jam

(14/9/2023) KOAGULASI
PPT 10.9 detik
APTT 29.7 detik
Chest Xray
USG Abdomen
CT SCAN
 PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning Planning Therapy &
Diagnosi Monitoring
s
Anamnesis: • Mild TBI (GCS 346) - - Wound care
Main Complaint : loss of consciousness & • Closed fracture os - IVFD RL 20 tpm
headache after being beaten, stepped on costae 5 D anterior - Inj. Ketorolac 30mg
and kicked • Blunt thoraco- - Inj. Citicolin 250 mg
- still drunken by alcohol abdominal trauma - Inj. Piracetam 3 gr
- fainted (+), headache (+), nausea, vomiting - Observe clinical
(-), retrograde amnesia (+), otorhea (-), features/ICP
rhinorhea (-) 2x24hours
GCS: 346 somnolens
BP : 183/89 mmHg
HR: 65x/minute
RR: 19x/minute
T: 36,5 C
SpO2 : 99% on RA
 Problem list Definitive Diagnosis Planning Planning Therapy &
Diagnosis Monitoring

Localist status • Mild TBI (GCS 346) - - Wound care

Temporalis S Region • Closed fracture os - IVFD RL 20 tpm
Look: vulnus laceratum ±1x3cm with base of costae 5 D anterior - Inj. Ketorolac 30mg
dermis and irregular borders, edema (+), • Blunt thoraco- - Inj. Citicolin 250 mg
hematoma (+), active bleeding (+), abdominal trauma - Inj. Piracetam 3 gr
Feel: tenderness (+), crepitus (-) - Observe clinical
Facial Region features/ICP
Look: multiple vulnus abrasion et contusio, 2x24hours
hematoma (+), active bleeding (-)
Feel: tenderness (-), crepitus (-)
Thoracic Region
Look: multiple hematoma, erythema (+)
Feel: tenderness (+), crepitus (+) at costae 5
dextra anterior
Back Region (Logroll)
Look: multiple hematoma and contusion,
erythema (+)
Feel: tenderness (-), crepitus (-)
 Problem list Definitive Planning Planning Therapy &
Diagnosis Diagnosi Monitoring
s

CXR: Discontinuity of os costae 5 dextra anterior • Mild TBI (GCS - - Wound care
346) - IVFD RL 20 tpm
CT scan Non Contrast • Closed fracture - Inj. Ketorolac 30mg
Subgaleal hematome on regio frontoparietal os costae 5 D - Inj. Citicolin 250 mg
sinistra anterior - Inj. Piracetam 3 gr
Narrow sulci sylvian fissures and flat gyri without • Blunt thoraco- - Observe clinical
hyperdense lesions abdominal features/ICP
trauma 2x24hours
USG Abdomen: no free fluid in intra cavum
abdominal & intact organs
THANK YOU