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    1. A 43-year-old man presented with left eye pain and blurry vision after falling off his motorcycle without a helmet the previous evening. 2. On examination, he had a 4x3cm open wound on his left lower eyelid affecting the eyelid margin. His left eye also showed eyelid swelling and conjunctival hyperemia. 3. His initial diagnosis was an open wound of the left periorbita. Labs were ordered and treatments planned including IV fluids, antibiotics, and pain medications. Close monitoring of his condition, vision, and wound was planned.

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    1. A 43-year-old man presented with left eye pain and blurry vision after falling off his motorcycle without a helmet the previous evening. 2. On examination, he had a 4x3cm open wound on his left lower eyelid affecting the eyelid margin. His left eye also showed eyelid swelling and conjunctival hyperemia. 3. His initial diagnosis was an open wound of the left periorbita. Labs were ordered and treatments planned including IV fluids, antibiotics, and pain medications. Close monitoring of his condition, vision, and wound was planned.

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    6 views15 pages

    Morning Report

    Uploaded by

    vindypalupi
    1. A 43-year-old man presented with left eye pain and blurry vision after falling off his motorcycle without a helmet the previous evening. 2. On examination, he had a 4x3cm open wound on his left lower eyelid affecting the eyelid margin. His left eye also showed eyelid swelling and conjunctival hyperemia. 3. His initial diagnosis was an open wound of the left periorbita. Labs were ordered and treatments planned including IV fluids, antibiotics, and pain medications. Close monitoring of his condition, vision, and wound was planned.

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    of 15

    Morning Report

    December 2nd 2013

    Identitas
    Name: Sdr. Mufti
    Age: 43 y.o
    Address : Bulubrangsi

    Anamnesis
    Keluhan Utama: Nyeri pada mata
    RPS: Pasien post KLL jam 5 sore. Pasien
    jatuh sendiri dan tidak memakai helm.
    Pasien mengeluh nyeri pada luka di
    daerah mata sebelah kiri. Pasien juga
    mengeluh bahu sebelah kirinya nyeri jika
    digerakkan. Mual-. Muntah-. Pandangan
    kabur-.

    History or pass illness :


    - HT - DM + Tidak rajin kontrol
    History of family:
    History of sociality:
    - Smoke
    - Alcohol

    Physical
    examination:
    General status
    GCS : 456
    Vital Sign:
    BP
    : 129/57 mmHg
    Pulse : 101/mnt
    Temp : 360C
    RR
    : 21/mnt
    Head/neck
    An -, ict-, cy-, dys-,
    JVP normal.

    Thorax
    Symmetric, retraction
    (-), sonor, murmur (-),
    gallop (-)
    ves/ves, rh +/+, wh -/Abdomen
    flat, Supple, discomfort,
    hepar lien unpalpable,
    thimpany, bowel sound
    (+) N,
    Extremity
    Warm, dry, red,
    oedema,

    Status lokalis
    Vulnus appertum palpebra inferior mengenai
    kantus dan margo palpebra inferior 4x3cm
    Visus OS : > 2/60 berbaring
    Visus OD : > 2/60 berbaring
    OD : hiperemi konjungtiva
    OS : hiperemia konjungtiva, edem palpebra

    Clue and Cue


    Vulnus appertum palpebra inferior sinistra
    Edem palpebra sinistra
    Konjungtiva hyperemi

    Problem List
    Vulnus appertum palpebra inferior sinistra

    Initial Diagnosis
    Vulnus appertum periorbita

    Planning Diagnosis

    DL
    GDA
    Profil lipid
    Bleeding & clothing time
    EKG
    Ro skull AP/Lat
    Ro thorax

    Laboratory Findings
    Diff count: 0/0/79/18/3
    Hematocrite: 39,1 %
    Hb 13,1 mg/dl
    Leukocytes : 17.500
    platelets : 332.000
    GDA 245
    Bleeding time 2 00
    Clotting time 8 30

    Planning Therapy
    IUVD loading Asering 500 cc
    Inj ceftriaxon 2x1 gr
    Inj metamizole 3x1 amp

    Planning Monitoring

    Kondisi umum
    Vital sign
    Visus
    TIO
    Lapang pandang

    Edukasi
    Menjelaskan diagnosis pada pasien
    Menjelaskan terapi pada pasien
    Menjelaskan prognosis pada pasien

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