MORNING REPORT

SMF/ BAGIAN ILMU BEDAH

FK UNDANA RSUD PROF. DR. W. Z.
JOHANNES KUPANG

23th Dec 2016

 Identity

Name : Ny. M.U.

Sex : Female
Age : 33 years old
Religion : Katholik
Address : Maulafa
 Anamnese
Chief Complain :
wound to the bitten by dog
Present Complain:
Patients come with complaints of wound due to exposure
to dog bites on the left calf from one hour before entering
the hospital. Initially patients were wanting to enter the
gate of house suddenly there was a direct neighbors dog
attacked and bit him. Fever (-), headache (-), syncope (-),
nausea (-), vomiting (-), pain in the wound (+). Patients do
not know the characteristics of the dog. Patients have not
done any treatment.
Physical Examination
Primary Survey
A : Clear, patent
B : Spontan, RR 20 x/m
C : TD 120/80 mmHg, Pulse 92x/m, warm
D : GCS E4V5M6, Pupil isokor 3mm/3mm,
RCL +/+
E :
- Vulnus eskoriatum regio cruris posterior sinistra (1 cm
x 0,2 cm) edema (-), eritema (-), bleeding (-), pain (+)
Secondary Survey
HEAD :
Eyes : Hematom (-/-)
Conjungtiva : Anemis (-/-)
Sclera : Icterik (-/-)
pupil : isokor, 3mm/3mm, pupil reflects
(+/+)
Ears : othorea(-/-),
Nose : Normal
Mouth : Normal
Neck : Limphonodes (-)
 COR
S1/2 single, murmur (-), gallop (-)

PULMO
Inspeksi : Chest expansion symetric, retraction (-
)
Palpasi : mass (-), krepitasi (-)
Perkusi: sonor (+/+)
Auscultasi : Vesiculer (+/+) , Ronchi (-/-),
Wheezing (-/-)
 ABDOMEN
Inspection : mass (-), scar (-), wound (-)
Auscultation : peristaltics normal
Palpation : tenderness pain (-) , mass (-)
Percusion : timpany sound (+)
 EXTREMITY :
Look:

- Vulnus eskoriatum regio cruris posterior sinistra (1 cm

x 0,2 cm), edema (-), eritema (-), bleeding (-)
Feel : Pain (+), NVD normal
Movement : ROM normal
Diagnosis

Dog bite
Therapy

Wound toilet
Inj ATS 1500 IU IM
Amoxicilin 3 x 500 mg
Asam mefenamat 3 x 500 mg
THANK YOU