MORNING

REPORT
14 September 2023
Identity

● Name : Tn. M
● Age : 29 years old
● Gender : Male
● Weight : 60 kg
● Address : Batu
● Arrival Date : 14 September 2023
● Patient Type : Trauma
 PRIMARY SURVEY
Incident date: 14/09/23, at 11.00
Arrival Date: 14/09/23 , at 11.50

Anamnesis:
Main complaint: Decreased of conciousness
Anamnesis :Patient taken to ER with decreased consciousness post Traffic accident. After the incident there were
no symptoms of nausea, vomiting or fever. Retrograde amnesia (-), dizziness (-)

MOI: Car overturned because of sudden stop to avoid a motorbike who made a sudden turn and patient sat on the
driver seat

Examination Initial Diagnosis Action

Airway: - -
Paten (+) gargling (-), stridor (-), snoring (-)

Breathing: - Oksigen
Look: symmetrical chest wall movement (+), lesion (-), deformity (-)
Feel: the patient breathes spontaneously, no additional breath
sounds, rib crepitations (-), dyspnea (-)
RR: 20 x/minute
SpO2 : 96% on RA

Circulation: - EBV: 70X60= 4200

BP : 143/89 EBL: 15% X 4200= 630
HR: 95x/min, strong pulse
 PRIMARY SURVEY
Examination Initial Diagnosis Action

Disability :
 SECONDARY SURVEY

GENERALIST STATUS
GCS : 456
BP : 143/89
HR : 95 x/minute
RR : 20 x/minute
SpO2 : 96% on RA
 SECONDARY SURVEY

ANAMNESIS

Allergy :-
Medication : -
Past illness : GERD
Last meal : 13/09/23 at 21.00 WIB
Event : traffic accident car toppled. The
car overturned when the patient wanted
to avoid a motorbike who made a
sudden turn.
 PHYSICAL EXAMINATION
EXAMINATION
HEAD/NECK: THORAX :
Head: Cor:
Eyes: Diplopia (-), anemic conjunctiva (-/-), Inspection: ictus cordis invisible
icteric sclera (-), pupil isokor 3 mm/3mm, Light Palpation: ictus cordis palpable at ICS 5 MCL S
reflex direct and indirect +/+, hematoma Percussion: D heart border at ICS 4 PSL D,
periorbita (-/-) heart border S at ICS 5 MCL S
Nose: rhinorrhea (-/-) Auscultation: S1 S2 single, regular, murmur (-),
Ears: otorrhea (-/-) gallop (-)

Pulmo:
Inspection: normal chest wall shape, retraction
(-), lesion (-)
Palpation: tenderness (-), symmetrical D/S
chest wall movement
Percussion: sonor
Auscultation: vesicular +/+
 PHYSICAL EXAMINATION EXAMINATION
ABDOMEN:
Inspection : Flat, injury (-), surgical scar (-), lump (-)
Auscultation : Bowel sound (+) 11x/minute
Palpation : Flat, soft, superficial tenderness (-), deep tenderness (-)
Percussion : Timpany

EXTREMITIES :
Dry warm acral, CRT <2

Local status:
Elbow Region D:
L: Vulnus abrasion with a reddish base 6cm
F: Tenderness (+), warmth, krepitasi (-)
M: Limited ROM cause of pain

Manus Region D:
L: Vulnus Laceratum 1cm proksimal phalang digiti V
F: Tenderness (-), warmth, krepitasi (-)
M: ROM normal
Laboratory Examination
Hematologi (14/09/2023)
Hb 14.3
RBC 5.13
HCT 41.4
MCV 80.7
MCH 27.9
MCHC 34.5
WBC 7.22
EO% 0.7 L
BASO% 0.7
NEUT% 51.7
LYMPH% 39.6
MONO% 7.3
PLT 197
LED 10
CLINICAL PICTURES
 Other Examination

X-Ray
Elbow D
AP/Lat
(14/09/2023)
 Other Examination

CT Scan Head Non-Kontras Bone

Window (14/09/2023)
 Other Examination

CT Scan Head Non-Kontras Brain

Window (14/09/2023)
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Diagnosis Planning Therapy & Monitoring
Diagnosis

Anamnesis: • CKR 456 • IVFD RL 20 tpm

- •
Main complaint: Decreased of conciousness Inj. Ketorolac 30mg
• Vulnus Abrasi
Anamnesis : • Inj Ranitidin 50mg
• DOC After traffic accident Elbow D • Inj. Citicolin 250 mg
• Nausea (-) vomiting (-) dizziness (-) retrograde • Vulnus • Inj. Piracetam 3 gr
amnesia (-) • Head CT Scan NK
MOI : Car overturned because of sudden stop to Laceratum Digiti • X Ray Elbow (D) AP/Lat
avoid a motorbike who made a sudden turn and VD
patient sat on the driver seat
Status localist:
Elbow Region D:
L: Vulnus abrasion with a reddish base 6cm
F: Tenderness (+), warmth, krepitas (-)
M: Limited ROM cause of pain
Manus Region D:
L: Vulnus Laceratum 1cm proksimal phalang digiti
V
F: Tenderness (-), warmth, krepitasi (-)
M: ROM normal

CT SCAN: Edema cerebri

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