MORNING

REPORT
September 14th, 2023
  Name : An Nuha
 Age : 11 years old
Patient’s  Gender : Male

Identity  Address : Batu

 Arrival Date : September 14th, 2023
 Patient Type : Trauma
 ANAMNESIS

Incident date: 14/09/2023 at 17.13 WIB

Arrival time: 14/09/2023 at 16.15 WIB

Anamnesis:
Main complaint: pain on the penis

Current medical history:

The patient came to the ER with complaints of pain and bleeding from the genitals after being
kicked while practicing Silat (VAS score 8-9). A little blood comes out from the penis. Blood does
not come out of the OUE. There are no problems when urinating. Currently the patient has not
been given any intervention

MOI:
Pain in the penis after being kicked during Silat
 PRIMARY SURVEY
Examination Initial Action
Diagnosis
Airway: snoring (-), gurgling (-), stridor (-) -
Breathing: -
Look: Normal (symmetrically, scar -)
Feel: Normal (spontaneous, dyspnea -)
RR: 21x/minute
SpO2 : 98% on RA
Circulation: -
BP: 124/90 mmHg
HR: 128x/min, strong pulse
CRT<2s, Dry Warm Red Acral
Disability : -
GCS 456, isochoria pupil 3mm/3mm, Light reflex
direct and indirect +/+
Exposure: -
Dry Warm Red Acral; Temp: 36.1C
 PRIMARY SURVEY
Examination Initial Diagnosis Action

Local status:: Vulnus laseratum - Wound care (compress

Dry Warm Red Acral; Temp: 36.6C regio penis with NS and give
sulfadiazine cream)
Localist status
Regio Genitalia

Regio penis:
L: vulnus laceration on the dorsal penis (+), size 3cm, bleeding
on the OUE (-), active bleeding (-), Edema (-), Erythema (+)
F: pain (+) VAS score 8-9, warm (-)
M: pain when retracted

Regio scrotalis:
L: 2 testicles, erythema (-), edema (-)
F: pain (-), warm (-)
M: cremaster reflex (-),
 SECONDARY SURVEY

GENERALIST STATUS
ANAMNESIS

Allergy :-
GCS : 456 Medication : -
BP : 124/90 mmHg Past illness : -
HR : 109x/menit Last meal : 15.00 (14/9/2023)
RR : 20x/menit Event : Pain in the penis after
SpO2 : 97% on RA being kicked during Silat
Weight: 50 kg
 PHYSICAL EXAMINATION

THORAX :
HEAD/NECK:
Cor:
Head: a/i/c/d : -/-/-/-
Inspection: ictus cordis invisible
Eyes: isochoria pupil 3mm|3mm, Light reflex direct
Palpation: ictus cordis palpable at ICS 5 MCL S
and indirect +/+
Percussion: Cardiac border D at ICS 4 PSL D,
Ear: ottorhea (-/-) serumen (not evaluated)
cardiac border S at ICS 5 MCL S
Nose: deformity (-), bloody rhinorhhea (-)
Auscultation: S1 S2 single, regular, murmur (-),
Mouth: trismus (-), cyanosis (-)
gallop (-)
Neck:
Pulmo:
Inspection : tracheal deviation (-); laceration(-)
Inspection: normal chest wall shape
Palpation : palpable carotid artery pulsation, lymph
Palpation: symmetrical D/S chest wall movement,
node enlargement (-)
Percussion: sonorous
Auscultation: bruit (-)
Auscultation: Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL EXAMINATION

ABDOMEN:
Inspection : flat, scar (-), Localic status:
Auscultation : bowel sound 9x/min
Palpation : superficial & deep tenderness (-) Regio Genitalia
Percussion : tympanic
Regio penis:
EXTREMITY: L: vulnus laceration on the dorsal penis (+), size
Dry warm red acral, CRT <2 s, oedema (-/-) 3cm, bleeding on the OUE (-), active bleeding (-),
Edema (-), Erythema (+)
F: pain (+) VAS score 8-9, warm (-)
M: pain when retracted

Regio scrotalis:
L: 2 testicles, erythema (-), edema (-)
F: pain (-), warm (-)
M: cremaster reflex (-)
Clinical Pictures
 PROBLEM LIST & PLANNING
Planning Planning Therapy &
Problem List Initial Diagosis
Diagnosis Monitoring
Anamnesis: Vulnus laceratum - - Wound care (hecting)
• Pain in the penis (VAS Score 8-9) after slipping regio penis
on being kicked whilee playing silat.
• Bleeding on dorsal penis
• Urinating problems (-)
• Tingling (-) numbness (-)
• MOI: Pain in the penis after being kicked during
Silat.

Physical examination
GCS : 456
BP : 124/90 mmHg
HR : 109x/menit
RR : 20x/menit
SpO2 : 97% on RA
Weight : 50 kg
 PROBLEM LIST & PLANNING

Planning Planning Therapy &

Problem List Initial Diagnosis
Diagnosis Monitoring

Localic status: Vulnus laceratum - - Wound care (hecting)

Regio Genitalia regio penis

Regio penis:
L: vulnus laceration on the dorsal penis (+),
size 3cm, bleeding on the OUE (-), active
bleeding (-), Edema (-), Erythema (+)
F: pain (+) VAS score 8-9, warm (-)
M: pain when retracted

Regio scrotalis:
L: 2 testicles, erythema (-), edema (-)
F: pain (-), warm (-)
M: cremaster reflex (-)
 PROBLEM LIST & PLANNING
Definitive Planning Planning Therapy &
Problem List
Diagosis Diagnosis Monitoring
Anamnesis: Vulnus laceratum - - Wound care (hecting)
• Pain in the penis (VAS Score 8-9) after slipping regio penis - PO Ibuprofen 3x400mg
on being kicked whilee playing silat. - PO Cefixime syr 2x200mg
• Bleeding on dorsal penis - Gentamycin cream 4x1
• Urinating problems (-) (ue)
• Tingling (-) numbness (-)
• MOI: Pain in the penis after being kicked during
Silat.

Physical examination
GCS : 456
BP : 124/90 mmHg
HR : 109x/menit
RR : 20x/menit
SpO2 : 97% on RA
Weight : 50 kg
 PROBLEM LIST & PLANNING

Definitive Planning Planning Therapy &

Problem List
Diagnosis Diagnosis Monitoring

Localic status: Vulnus laceratum - - Wound care (hecting)

Regio Genitalia regio penis - PO Ibuprofen 3x400mg
- PO Cefixime syr 2x200mg
Regio penis: - Gentamycin cream 4x1 (ue)
L: vulnus laceration on the dorsal penis (+),
size 3cm, bleeding on the OUE (-), active
bleeding (-), Edema (-), Erythema (+)
F: pain (+) VAS score 8-9, warm (-)
M: pain when retracted

Regio scrotalis:
L: 2 testicles, erythema (-), edema (-)
F: pain (-), warm (-)
M: cremaster reflex (-)
Follow Up
THANK YOU