MORNING REPORT

DEPARTMENT OF SURGERY
(SHOFA)
APRIL 5TH 2015
 Patient identity

•Name : Mr. Fd
•Age : 21 years old
•Sex : Male
•Work : Student
•Address : Lamongan
•Examination date : April 5 th,
2015
 ANAMNESIS

Chief Complaint
•Dizzines

Present illness History

•Patients present with dizziness. The patient fell
from her motorbike and head was collided into
the asphalt 5 hours ago. Patients use a helmet
and was unconscious when the accident as
long 10 minutes, he patient complains of blood
out of the left ear. Nausea (+), vomiting (+),
Vertigo (+), tinnitus (+), fever (-)
Previously illnes history
• HT (-)
• DM (-)

Family illnes History

•-

Medicine taking history

•-

Social history
•-
Vital Sign
•GCS : 456
•Blood pressure : 144/69 mmHg
•Heart Rate : 96x /minutes
•RR : 20x /minutes
•Axilla temperature : 36.8o C
• Head : Normocepali, benjolan -, vulnus laceratum post hecting
diperban 6 cm at regio frontal dextra, nyeri tekan (+)
• Eye : Brill hematom -, hematom palpebra +/-, oedem palpebra -,
anemis -, ikterik -, pupil bulat isokor, R. Cahaya +/+
• ear : Normotia, Otorea (-), perdarahan -/+, Battle’s sign (-), tinnitus -
/+
• Thorax : Normal chest form, retraction (-),
unsymmetrical chest wall movement
• Pulmonary
• P : Frem n / n
• P : sonor/sonor
• A : ves/Ves, Rh-/-, Wh -/-
• RR : 20x/minutes
Cor
• A : S1-S2 single, murmur (-), gallop (-)
• Abdomen
• I : flat
• P : soefl, Liver / Splen not palpable
• P : thimpany
• A : Bowel sound (+) Normal
• Extremity : warm, dry, red
 STATUS NEUROGIS

• Maningeal sign : -
• R. Cahaya +/+
• N. VII : Bersiul : Simetris
Menutup mata : Simetris
Kerut Dahi : Simetris
Tersenyum : Simetris
• N. XII : Deviasi Lidah : Tidak ada
Tremor Lidah : Tidak ada
• R. Fisiologis BPR : +2/+2, TPR +2/+2, KPR +2/+2, APR
+2/+2
• R. Patologis : Babinski -, Chaddock -
 ASSESSMENT
• Cedera kepala Ringan
 PLANNING DIAGNOSIS

•DL
•CT-Scan
 LABORATOTY FINDINGS

•Leukocyt 11.600
•Hemoglobin 13.7
•Hematrokit 40.6
•Trombosit 207.000
•LED1 7
•LED2 15
•GDA 98
CT-SCAN
 CLUE AND CUE

• Male, 21 years old

• dizziness
• Vulnus laceratum 6 cm
at regio frontal dextra
• bleeding in the ear
sinistra
• Vertigo
• Tinnitus
• Nausea
• Vomit
• Unconscious 10
minutes
 SECONDARY ASSESSMENT

• CKR (Cidera kepala

Ringan)
 PLANING TERAPI

• IVFD Asering 1500cc/24 jam

• Inj. Piracetam 4x3 mg
• Inj. Ondancetron 3x8 mg
• Inj. Metamizole 3x1 amp
• Inj. Ranitidin 2x1 amp
• Tinggikan posisi kepala 30⁰
• C/ SpBS
 MONITORING

• Complaint
• Vital sign
 PROGNOSIS

•Dubia ad Bonam