MORNING REPORT

APRIL 29
TH
2013
Konsulen dr. Jean Pello, SpB

1
St
Case
BIODATA
Name : MD
Age : 4 years old
Sex : Male
Address : Sikumana


Anamnesis
Chief Complaint : Fell from the car
MOI
patient come to ER because of falling from the parked car several
minutes ago. The child cry a lot and blood was over the face. Theres a
wound at the right forehead. The kid didnt loss the consciusness, no
nausea, no vomit, but theres headache presents. Theres no other
wound or other complaints.
Primary Survey
A: Patent, clear
B : RR: 24 times/min, spontan
C : CRT : <2, Pulse: 92 times/minute, reguler.
D : GCS E4V5M6
E : V. Laceration on region Frontal dextra, 2cm
Secondary Survey
GCS : E4 V5 M6
Head : Normal
eyes : anemic (-/-), light reflex (+/+), icteric (-/-) ,
isokhor +/+
Ear : normal
Nose : normal
Neck: Normal
Thorax
Inspection : chest expansion simetrics, reguler,
abdominothoracal, Bruish (-)
Palpation : vocal fremitus R=D, krepitasi (-),
Pain (-)
Percusion: sonor (+/+)
Auscultation : vesicular (+/+), ronchi (-/-),
wheezing (-/-)

Abdomen
Inspection : look flat, follow the chest
expansion
Palpation : pain (-), mass (-), tenderness (-)
Percusion : timpany (+)
Auscultation : peristaltics (+), normal


Extremity

Look (normal)
Feel normal
pain (-)
Move
ROM : normal

Assessment
Vulnus laceratum at regio frontal dextra
Planning therapy
Wound toilet and primary hecting
Anti tetanus serum
Paracetamol 250 mg 3x1 tab
Amoxicillin 250 mg 3x1 tab
Picture
Patient Identity
Name : Mrs. WN
Sex : Female
Age : 51 y.o
Religion : Catholic
Job : Housewife
Adress : Soe
History

Chief complaint: shortness of breathe 2 days before
hospitalize
MOI:
Shortness of breath has been felt for a long time, experienced again 2
days after patient received an introductory home from the hospital.
Patients treated till date 21/03/14 04/26/14 26 with a diagnosis of ca.
mammary sinistsra. Ca experienced since 2009, breast surgery. In
2012 appeared the bump, bump in 2013 turned into a wound. August
2013 appear small bumps around the left breast to the right spread to
the neck and armpits. The bumps on the left side neck pain when
touched. Because it is often shortness of breath, in 2014 the patient
had 6 times the puncture lung fluid, four times in the left lung and right
lung 2 times. Bumps that have become wound was cut then sent for
examination, then the result is 2 weeks out. 2 months ago while being
treated, the patient's legs and hands swelled. History urinating blood
while being treated. unconsciousness (-), nausea (+), vomit (-),
dizziness (-).
Habit history: smoke five to six cigarettes / day
since the age of 21 years and drank alcohol
Primary Survey
Airway: clear
Breathing: 36 x/min
Circulation:
Pulse: 97x/min
Disability: E4V5M6
Exposure : covered with gauze


Secondary Survey
GCS E4V5M6
Head: simetric, normocephal
Eye : anemic (-/-), light reflex (+/+), icteric (-/-),
isokor (+/+)
Ear : Normal
Nose : Normal
Mouth : Normal
Neck: enlarged lymph nodes (+), multiple, cervical
region, axilla region, chest region. Size: 1cm,
elastic, immobile, tenderness (+)
Throat : Normal
Thorax
Inspection : chest expansion simetrics, reguler,
Palpation : edema (-), crepitation (-), tenderness (-)
Percusion : sonor (+/+)
Auscultation : vesicular (+/+), ronchi (+/+), wheezing(-/-)

Abdomen
Inspection : flat, mass (-), wound (-)
Auscultation : peristaltics (N)
Palpation : tenderness pain (-)
Percussion : timpanic sound (+)
Extremity
Look
Deformitas (-), shortening (-), lengthening (-), swelling
(+)
Feel
CRT <2, warm, pulsation of a. Dorsalis pedis sinistra
and dextra (+), Sensoris (+), crepitation (-)
Move
Normal


Workup
Chest X-ray
CBC
Complete urine count
Asessment

Ca mammae sinistra
Dyspnoe e.c metastasis pleura
Limfodenitis
Management
O2 4 lpm
IVFD RL 10 tpm
If leucocytosis Ceftriaxon 2x1gr iv

Picture


Case 3
Identity
Name : Mr. TB
Age : 22 y.o
Sex : Male
Address : Camplong

History Taking
Chief Complaint: Burn wound
Present Complaint: Patient presented w/ painful
burn wound existed from a day ago, resulted from
falling on top of a flaming cooking stone stove
while squatting in front of it. Toothpaste was
applied on his burn wound before he was
admitted at RS Naibonat.
Physical Examination
Primary Survey
A: Clear
B: spontaneous breathing with RR of 20
C: Pulse rate: 88
D: Alert (GCS: E4V5M6)
Secondary Survey
Hair : Black, Allopecia (-)
Eyes :
Conjungtiva : Anemic (-/-)
Sclera : Icteric (-/-)
Ears : Normal
Nose : Normal
Mouth : Normal
Neck : Lymphadenopathy (-)

Physical Examination
PULMO
Inspection: symmetrical chest expansion
Palpation : Vocal fremitus (d=s), mass (-),
crepitation (-)
Percussion: sonor (+/+)
Auscultation : Vesiculer (+/+),Ronchi (-/-),
Wheezing (-/-)
COR
S1/2 single, murmur (-), gallop (-)

Physical Examination
ABDOMEN
Inspection : Flat, suitable with breathing
Auscultation : normal peristaltic sound
Palpation : Tenderness (-)
Percussion : Tympanic sound

Local status
Location; face, neck, distal 2/3 of the left arm,
medial 1/3 of right upper arm.





Lab Results
DL
WBC: 24,64
Lymph: 1,84
Mono:1,48
Eo:0,52
Baso: 0,03
Neut:20,77
RBC13,56
HGB 14,9
HCT 43,6
MCV 78,4
MCH 26,8
MCHC 34,2
PLT 206
UL
BJ: 1.020
pH 6,0
Lekosit +3
Nitrit (-)
Glukosa N
Protein N
Urobilinogen N
Keton (-)
Bilirubin (-)
Eritrosit +3

Sedimen
Lekosit penuh
Eritrosit 15-20/lp
Epitel 15-20/lp
Silinder (-)
Kristal (-)
Bakteri (-)

Lab Results
Ureum 16,1
Creatinin 0,3
GDS 133
Na 137
K 4,2
Cl 104
Planning
Plasma Albumin
Assessment
Grade 2 burns with 17% body area
involvement
Planning Therapy
Wound Toilet
Burnazine zalf
Inj ATS 1 amp IM
IVFD RL 20 tpm
Inj. Omeprazole 1 amp IV
Inj. Cefotaxime 2x1 gr IV