Morning Report

Morning ReportAugust 15th 2015Hospitalized Patient: 3 patientAmbulatory Patient: 1 patientTotal: 4 patientsAmbulatory PatientMr. S, 30 y.o. Vulnus Laceratum et regio cephal. Hospitalized PatientName: Mrs. SAge: 47 years oldReligion : IslamOccupation : HousewifePrimary SurveyAirway: ClearBreathing: Spontan, 24x/minuteCirculation: BP: 130/70mmHg, Pulse: 84x/minute, CRT < 2Disability: AlertExpossure: -Secondary SurveyChief Complain:Benjolan di belakang leher yang terasa nyeri Secondary SurveyHistory : Pasien datang dengan keluhan terdapat benjolan di leher belakang sejak 15 hari SMRSExamination from Head to ToeHead : Normocephal, injury (-)Eyes: Pupil isochor 3mm/3mm, Light Reflex (-/-)ENT : Bleeding (-), deviation of trachea (-)Neck : Injury (-), Pain (-)Chest: Pain (-), Dispnea (-)Cor : S1,S2 regular, M(-), G(-)Pulmo : VBS (+/+), Wh (-/-), Rh (-/-)Abdomen : Soepel, tenderness (-), Bowel sound (+) N.Hepar and Lien: NormalExtremity: perifer perfusion : cold, pale, crt>2

Physical ExaminationGeneral Status: NormalLocal Status: Left wristLook: theres an open wound on her left wrist with 8 cm long and 4 cm width, active bleeding(+)Feel: swollen (-), tenderness (+), CRT >2, Move: limited ROM

Planning of additional examinationDL, GDS, SGOT-SGPT, Ur, Cr, BT, CT, HBsAgRo wrist Joint AP/Lateral sinistraRo Thorax PALaboratory FindingsHb: 8,0HCT : 25,5PLT: 265.000WBC : 21,4GDS : 208Hbs Ag : ReaktifBT : 430CT : 600SGOT : 22SGPT : 23Ur : 3,6Cr : 1,1

Working DiagnosisSchizum Wound of vollar wrist sinistraSuspect Rupture tendonSuspect rupture median nerveSuspect rupture radial arteryTreatmentIVFD RL 20 tpmOpimer 2x1 grKetorolac 3x30 mgATS 1500 IU/IMPlanning for OperationInformed ConsentFasting 6 hours before opConsultation with aenesthesiologist

Thank you