MORNING

REPORT
11 September, 2023
IDENTITY

● Name : Mrs. Chabibah

● Age : 69 years old
● Gender : Female
● Address : Batu
● Arrival Date : September 15, 2023
● Patient Type : non Trauma
 ANAMNESIS

Main Complaint:
Pain at backhead

Curent Medical History:

Headache that doesn't feel like it's spinning. Dizziness (+), nausea (-)
vomiting (-) Retrograde amnesia (-). Urination (normal), Defecatio
(normal), dementia

MOI : The patient fell while walking home and then hit the back of his
head on the floor. After falling, the patient could not stand up and be
supported by his family
 Primary Survey Initial Diagnosis Action
Airway: Paten -
Patent, gurgling (-), stridor (-)
Breathing: Spontan -
Look: symmetrical chest wall movement
Feel: the patient breathes spontaneously, no
additional breath sounds, rib crepitations (-), step
defect (-)
RR: 18x/minute
SpO2 : 97% on RA

Circulation: Maintenance fluid 10 kg I : 40 ml/ jam

BP: 172/80 mmHg HR: 94 x/m 10 kg II : 20 ml/ jam
CRT <2s, red dry warm acral 10 kg III : (35-
Active bleeding (-) 20)=15 ml/ jam
 Examination Initial Action
Diagnosis
Disability - -
GCS: 456. PBI: 3 mm/3mm. Direct light reflex
+/+, Indirect light reflex +/+
Exposure - -
T : 35.9 ° C
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK:
Cor:
Head: Inspection: ictus cordis invisible
Head/neck: a/i/c/d -/-/-/- 2mm/2mm Palpation: ictus cordis palpable at ICS 5 MCL S
isochor pupils, RCL -/-, RCTL -/-, visual Percussion: D heart border at ICS 4 PSL D, heart border S
acuity ODS SDE at ICS 5 MCL S
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)
Neck :
Inspection: tracheal deviation (-) Pulmo:
Palpation: enlarged lymph nodes (-) Inspection: normal chest wall shape, retraction (-)
Palpation: symmetrical D/S chest wall movement
Auscultation : Bruits (-)
Percussion: sonor
Auscultation:
Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL EXAMINATION

Local Status
Abdomen
Parietal area :
Inspection:
L : Vulnus laceratum size 1 cm active bleeding
Flat, inflammation (-) scar (-) eritem (-)
(+)
Auscultation : BS (+)
F : Pain on palpation (+), Crepitation (-), step
Abdominal percussion: timpany
defect (-)
Abdominal Palpation:
M:-
Tenderness (-) superficial and deep (SDE).
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---
---

Extremity:
Dry red warm akral ++/+-, CRT> 2, edema
--
--
 SECONDARY SURVEY GENERALIST STATUS
S : Headache reduced
A:- KU : composmentis
M : Candesartan 1x8 mg, GCS : 456
Cilostazol 1x100 mg, BP : 141/71mmHg
Flunarizine, Obat racikan HR: 79 x/m
P : HT Controlled, DM -, CVA >3 RR : 22 x/m
th routine controlled with dr. T : 37,3 C
SpS SpO2 96% on RA
L : 09.00 BB: 70 kg
E : Falling down when want to
walking
Laboratorium
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Planning Therapy
Diagnosis Diagnosis
Mrs. C, 9 YO, Headache that doesn't feel like it's spinning. • Susp Normal • CT Scan • Bed rest
Dizziness (+), nausea (-) vomiting (-) Retrograde amnesia (-). Pressure head • Head up 30°
Urination (normal), Defecatio (normal), dementia Hydrocephalus • Inj. Ketorolac 30 mg
• Inj. Ranitidin 50 mg
• KU : composmentis • Inj. Piracetam 3x30
• mg
GCS : 456
• Inj. Citicolin 2x250 mg
• BP : 141/71mmHg • Inj. Ceftriaxone 2x1 g
• HR: 79 x/m
• RR : 22 x/m
• T : 37,3 C Monitoring
• SpO2 96% on RA • TTV
• BB: 70 kg • Skala Nyeri

Pemeriksaan fisik
• K/l: a/i/c/d : -/-/-/-
• Tho: Ves +/+ Rh (-/-) , wh (-/-)
• Abd: soefl, nyeri tekan (-)
• Ext: AKHM, CRT <2 s
CT Scan Skull
View
CT Scan Skull
View
THANK YOU
Ny. Chabibah/69 th/3G/CKR 456/dr. Dana, Sp.B P
RL 20 TPM
S: Nyeri kepala tidak terasa, pusing (-), mual (-) muntah Inj. Ketorolac 30 mg
(-) Inj. Ranitidin 50 mg
Inj. Piracetam 3x30 mg
O GCS : 456TD : 125/60 mmHgN : 66 x/m RR : 18 x/m Inj. Citicolin 2x250 mg
T : 36,5° CSpO2 94% on RA Inj. Ceftriaxone 2x1 g

Pemeriksaan fisik
K/l: a/i/c/d : -/-/-/-Tho: Ves +/+ Rh (-/-) , wh (-/-)Perkusi
sonor +/+ simetris
Abd: soefl, nyeri tekan (-)
Ext: AKHM, CRT <2 s

A
CKR 456, Vulnus laceratum regio parietal