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    Morning Report: March 4, 2021

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    Alif Binangkit

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    © All Rights Reserved
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    Morning Report: March 4, 2021

    Uploaded by

    Alif Binangkit
    13 views15 pages

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    MR 4 maret.pptx

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    © All Rights Reserved
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    13 views15 pages

    Morning Report: March 4, 2021

    Uploaded by

    Alif Binangkit

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 15

    MORNING REPORT

    March 4th, 2021


    IDENTITY
    Name : Mr. B
    Gender : Male
    Age : 54 years old
    Date of birth : August 13th, 1967
    Address : Jl. Wijaya Kusuma 9 No 41 Mayangan,
    Probolinggo
    RM Number : 313180
    Time of assessment : March 3th, 2021 (10.28 am)
    PRIMARY SURVEY
    Time of assessment: March 3th, 2021 (10.30 am)

    MOI: The patient's fell from 3 meters high bamboo ladder


    Primary Survey Assessment Stabilitation
    A Gurgling (-), snoring (-) Airway patent
    Spontaneous breathing, 24 tpm,
    B Breathing problem (+) NRM mask 15 lpm
    symmetry +/+, sonor +/+, vesicular +/+
    Strong pulse and regular 100 bpm; CRT
    C Circulation problem (-)
    <2 seconds; SpO2 97%, temp 36,6⁰C
    Respond to painful stimuli, round
    D Disability problem (+) 30° head-up position
    pupils, isokor 3mm/3mm, light reflex +/+
    Elastic bandage and splint attached Maintain stabilization with
    E Exposure problem (+)
    on right leg elastic bandage and splint
    SECONDARY SURVEY
    Time of assessment: March 3th, 2021 (11.15 am)
    Secondary Survey
    B1 Spontaneous breathing, 20 tpm, symmetry +/+, sonor +/+, vesicular +/+
    Blood pressure 170/60 mmHg, strong pulse and regular 100 bpm; CRT <2 seconds;
    B2
    SpO2 100%, temp 36,6⁰C
    B3 GCS E2V2M5, round and isochoric pupil, light reflex +/+
    B4 Urinate with urinary catheter
    B5 Tenderness (-), bowel movement (+), bruises (-)
    Elastic bandage and splint attached on right leg
    L: Splint and elastic bandage on right leg
    B6 F: pain (difficult to evaluate), a. tibialis posterior pulsation (+), a. dorsalis pedis
    pulsation (+)
    M: difficult to evaluate
    Chief Complain Unconcious and deformity on right thigh
    Current Medical On 02/03/2021 morning, the patient fell from 3 meters high bamboo ladder
    History on his way to go down after painted his house’s roof tile while holding a
    basket of paint on his left hand. His neighbor found him unconcious at 8am
    with the patient’s nose bleed and vomitting more than 5 times. Then, the
    patient’s family brought him to hospital in Probolinggo. In the hospital in
    Probolinggo, the patient have received some treatments, there are
    bandaging his thigh with elastic bandage and inserting urinary catheter. The
    patient referred to RSDS on 03/03/2021 at 10.30 am.
    Allergy (-)
    Medication Glibenclamide
    Past medical history Hypertension and Diabetes Mellitus
    Last oral intake 06.30am (02/03/2021)
    Event leading up to Fell from 3 meters high bamboo ladder
    incident
    Generalis Head Shape : Normocephali
    Status Eye : Light reflex (+/+), PBI, Ø 3 mm/3 mm
    Mouth : Sianosis (-)
    Ear : Secrete (-), bleeding (-)
    Nose : Secrete (-), epistaxis (-)
    Thorax Inspection: Retraction (-), symmetrical chest wall shape (+),deformity (-)
    Palpation: the movement of the right and left chest wall is symmetrical,
    crepitation (-)
    Percussion: Pulmo : sonor (+/+)
    Cor : left border ICS 5 midclavicula line sinistra
    Auscultation: Pulmo : vesikuler +/+, rhonki -/-, wheezing -/-
    Cor : S1S2 single, reguler, murmur (-), gallop (-)
    Abdomen Inspection: Flat, tenderness (-), bruises (-)
    Auskultation: BU (+) Normal
    Percussion: Timpany (+)
    Palpation: Soepel (+), defans muscular (-)
    Extremitie Warm extremities, oedema (-)
    s
    Local Status Oculi Look : Racoon eye (-/-), anemic (-/-), icteric (-/-), round and isochoric
    Region pupil 3mm/3mm, hematoma on superior palpebra dextra
    Feel : Difficult to evaluate
    Move : Difficult to evaluate
    Right Look : Covered by splint and elastic bandage
    Lower Feel : Pain (Difficult to evaluate), a. tibialis posterior pulsation (+), a.
    Limb dorsalis pedis pulsation (+)
    Region Move : Difficult to evaluate
    Diagnostic Planning
    • Head CT-Scan
    • AP/Lateral Cervical Spine X-Ray
    • AP Pelvic X-Ray
    • AP Femur X-Ray Dextra
    Assesment
    Moderate Brain Injury + ICH + SDH + CF Intertrochanter
    Femur Dextra
    Therapy Planning
    • EDH and ICH Evaluation
    • Pro ORIF
    • Inf PZ 20 tpm loading 500 cc
    • Inj Omeprazole 2x1 amp
    • Inj Ondansentron 2x8 mg
    • Inj Ketorolac 3x1 amp
    Thank You

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