MORNING REPORT

Kamis 20 -12-2012

BIODATA

Name : Putra aditia Age : 7 years old Sex : Male Address : Nunleu-Oebobo Job : Student Weight :22 kg Immunization : Complete Arrive to hospital : 20 Desember 2012

jam 13.10

Anamnesis

Chief Plaint : wound to the head

History TakingPatients come in with a head injury from a fall in the river as much as three

Mechanism of Injury Pastients falls in the river as high as two meters , while playing in the river. The patient’s head hit the stone to make the patient head was torn an bleeding three pieces

Primari Survey

A: Clear, paten B : RR: 18 times in a minute,

symetric, abdominotorakal type. C : Blodd preasure : 90/60mmHg,

heart rate : 78 times/minute D : (-) E : Vunus laceratum parietal regio Hematom in ocipital regio

Secondary survey

GCS : E4 V5 M6 Eye : anemis (-), pupils refleks +/+ Ear : otorhuoe (+/-) Nose : Rhinoroe (-/-)

Head

Vunus laceratum parietal regio Hematom in ocipital regio

Toraks

Inpeksi : cheest floating simetric, mark injury (-)

Palpation : crepitation (-), pain (-) Perkusion : sonor (+/+) Auscultation : breath sound is

vesicular

Abdoment

Inspektion : no lession Auscultation : intestinal sound (+) Palpation : tenderness paint (-) Perkusion : thympani all of quadrant

Extremity

Look : No injury, free Movement

Feel : Pain (+)

Move: ROM normal

Assesment

Mild Head Injury Vunus laceratum parietal regio

Planning Therapy

Wound Toilet Wound Hacting Amoxicilin 3 x 250 mg Asam mefenamat 3 x 250 mg

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