L/O/G/O

MORNING REPORT
 IDENTITY

Name : Tn. A
Age : 34 years old
Adress : Morosi
Admission : April, 23th 2019
Doctor in charge : dr. H. Syamsul Rijal, Sp.B
 HISTORY TAKING
• Chief complaints : Facial Pain
• Anamnesis : Patient came to Bahteramas hospital with facial pain
since 2 hours ago due to occupational accident
• Mecanism of trauma : Patient was climbing the hydraulic ladder,
suddenly the ladder support was detached then the patient falls
from a height 2 meters with the position of the face knocked on
the iron ladder.
• History of trauma :
 There was history of syncope (-), nausea and vomit (+)
 History of alcohol and drugs consumption (-)
• History of treatment (-)
PRIMARY SURVEY
A Clear, Cervical Spine Control

RR 22x/min, regular, spontaneous B

C BP 170/100 mmHg
HR = 84x/min regular

GCS 15 (E4V5M6 pupil isochors,

Ø : 2.5mm/2.5mm, light reflex +/+) D
E T = 36,60 C (axillary)
 secondary survey
Generalized status

• Head : Localized state

• Eyes : within normal limit
• Nose : within normal limit
• Mouth : Localized state
• Ears : within normal limit
• Neck : within normal limit
• Chest : within normal limit
• Abdomen : within normal limit
• Upper limb : within normal limit
• Lower limb : Localized state
 secondary survey
Localized status

• Right Occipital Region

I : Deformity (-), hematome (-), swelling (+), wound (-)
P : Tenderness (+)
• Facialis Region
I : Deformity (+), avulsion of teeth (11, 12), hematome (+), swelling (+), wound (+)
vulnus laceratum oris region 0.8cm X 0.2cm
P : Tenderness (+)
• Left Thigh Region
I : Deformity (-), hematome (-), swelling (-), wound (+) vulnus excoriatum 11cm X
3.5cm
P : Tenderness (+)
Clinical Finding
D
I
A
G
N Mild Head Injury GCS 15 (E4M6V5) +
O Facial Trauma
S
E

8
 PLANNING EXAMINATION :
X-ray Skull AP-L, CT- Scan Skull,
•Routine blood

X-Ray Skull
AP/L Position
 MANAGEMENT

Farmakologi
Non farmakologi IVFD
• Oxygen via mask Analgetic
Antibiotic
Antihemorragic

CONSULT GENERAL SURGEON

L/O/G/O

Thank You

BAGIAN ILMU
BEDAH