MORNING REPORT Enha Muthia Firdiyanti

IDENTITY
Name : Ch. Aditia
Age : 3 y.o
Sex : Male
Address : Besulutu, South Konawe
Admission : November 4th 2019
DPJP : dr. Wayan Eka, Sp. B
HISTORY TAKING
• Chief Complainment :
Bleeding from the ears and nose
• Anamnesis :
The patien was given a lump of wood an hour ago
• MOT :
The patient is playing around a chunk of wood and then accidentally pulls one of the
wood so that the wood falls on the patient
• HOT :
He had anconcsciousness. He had no throw up. He has nose bleeding and left ear
bleeding
PRIMARY SURVEY

A There is an airway obstruction

B RR : 42 breaths/min
C Blood Pressure : 100/70 mmHg, Pulse rate :95 bpm
D E4M5V2 (GCS 11)
E Temperature : 35,4º C
SECONDARY SURVEY
• Generalized state :
Somnolen, Severe illness
• Localized state :
Regio Temporal (S) I : Swelling (+), Hematom (-), Deformity (-), Wound (-)
P : Crepitation (-), Tenderness can’t be assessed
PLAN OF DIAGNOSE
• CT- Scan
• Laboratory Test:
 Routine blood test
 Clotting time/ Bleeding time
 Blood chemistry test
LABORATORY FINDINGS
Result Unit Normal Result Unit Normal
Hematology Leukocyte
Hemoglobin 8.9 g/dl 12.0 – 16.0 NEUT 8.92 + 10^3/uL 1.50 – 7.00

Leukosit 24.83 10^3/uL 4.0 - 10.0 LYMPH 2.57 10^3/uL 1.00 – 3.70

Trombosit 467 10^3/uL 150 – 450 MONO 0.85 + 10^3/uL 0.00 – 0.70

Hematokrit 26.3 % 37.0 - 48.0 EO 0.15 10^3/uL 0.00 – 0.40

MCV 35.9 fL 80.0 – 97.0 BASO 0.03 10^3/uL 0.00 – 0.10

MCH 25.9 Pg 26.5 – 33.0

MCHC 33.8 g/dl 31.9 – 37.0
PCT 0.44+ % 0.17 - 035
CT- SCAN
DIAGNOSE
TCS
MANAGEMENT
• Non-pharmacology
 Bed Rest
 Education
• Pharmacology
 IVFD
 Analgetik
 O2 8 lpm (mask)
 Antifibrinolitik
 PPI
 Anti convulsan
Consult to Orthopedic Surgeon