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    Morning Report Department of Surgery

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    David Ari Prawira
    A 44-year-old male farmer was referred to the hospital after a motorcycle accident. He complained of head pain after falling from his motorcycle during a collision. On examination, he had a 5 cm laceration on his right forehead with hematoma and swelling of the eyelids. He also had a 2x1 cm open nasal laceration with crepitus and epistaxis. A CT scan was planned to further evaluate for possible brain injury and fractures of the maxilla and nasal bones. He was started on oxygen supplementation, IV fluids, antibiotics, analgesics and anticonvulsants. His family was educated on his condition, treatment plan, and possible complications.

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    Morning Report Department of Surgery

    Uploaded by

    David Ari Prawira
    18 views19 pages
    A 44-year-old male farmer was referred to the hospital after a motorcycle accident. He complained of head pain after falling from his motorcycle during a collision. On examination, he had a 5 cm laceration on his right forehead with hematoma and swelling of the eyelids. He also had a 2x1 cm open nasal laceration with crepitus and epistaxis. A CT scan was planned to further evaluate for possible brain injury and fractures of the maxilla and nasal bones. He was started on oxygen supplementation, IV fluids, antibiotics, analgesics and anticonvulsants. His family was educated on his condition, treatment plan, and possible complications.

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    Morning Report 28 November - Copy - Copy

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    A 44-year-old male farmer was referred to the hospital after a motorcycle accident. He complained of head pain after falling from his motorcycle during a collision. On examination, he had a 5 cm laceration on his right forehead with hematoma and swelling of the eyelids. He also had a 2x1 cm open nasal laceration with crepitus and epistaxis. A CT scan was planned to further evaluate for possible brain injury and fractures of the maxilla and nasal bones. He was started on oxygen supplementation, IV fluids, antibiotics, analgesics and anticonvulsants. His family was educated on his condition, treatment plan, and possible complications.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    18 views19 pages

    Morning Report Department of Surgery

    Uploaded by

    David Ari Prawira
    A 44-year-old male farmer was referred to the hospital after a motorcycle accident. He complained of head pain after falling from his motorcycle during a collision. On examination, he had a 5 cm laceration on his right forehead with hematoma and swelling of the eyelids. He also had a 2x1 cm open nasal laceration with crepitus and epistaxis. A CT scan was planned to further evaluate for possible brain injury and fractures of the maxilla and nasal bones. He was started on oxygen supplementation, IV fluids, antibiotics, analgesics and anticonvulsants. His family was educated on his condition, treatment plan, and possible complications.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 19

    MORNING REPORT

    DEPARTMENT OF
    SURGERY
    By: B22

    Identity
    Name
    Age
    Occupation
    Address
    Date
    No RM

    : Tn. S
    : 44 yo
    : farmer
    : brondong lamongan
    : November, 27th 2015
    : 09.39.83

    Anamnesis

    Chief Complaint: pain in head injuries after falling from a motor


    cycle

    MOI: patient referrals from PKU blimbing with Severe brain injury.
    The patient complained of pain in the head wound after an
    accident sice at 07.00 PM. Patient fell from a motorcycle during a
    collision with another motorcycle in front of him because they do
    not turn on the lights. Then the patient unconscious and had
    vomited 2 times approxiately 1 cup medium. Containing food.
    Patient also did not wear a helmet. Headache (+), PTA (-)

    Past Illness History : DM and HT (-)

    Family Illness History : DM and HT (-)

    Social Illness History: -

    Vital Sign
    BP
    PR
    t
    RR

    :
    :
    :
    :

    94/56 mmHg
    91x/mnt
    36.2 0C
    18 x/mnt

    Primary Survey

    A: Clear, gargling (-), snoring (-), speak fluently (+),


    potential obstruction (-)
    B: spontan, RR 18x/mnt, ves/ves, Rh -/-, Wh -/- SaO2
    100% with O2 support NRM 10 lpm
    C: Acral WDR, CRT <2, N 91x/mnt regular, BP 94/59
    mmHg
    D: GCS 356, lateralisation (-), PBI 3mm/3mm
    E: temp 36,2 OC, vulnus app et regio supra orbita
    dextra panjang 5 cm heacting, hematome palperbra
    D et S, vulnus apperteum nasal 2x1 cm, krepitasi
    nasal (+), epitaxis (+) edema maxila D et S, floating
    maxila (+), fals movement (+)

    Secondary Survey

    GCS: 356.
    K/L: a-/i-/c-/d-, KGB (-), increased of JVP (-)
    Tho: symmetrical , ret -/P: ves /ves, rh -/-, wh -/C: S1S2 tunggal, murmur (-), gallop (-)

    Abd: defans muscular (-), met (-), BU+N, tendernes (-)


    Ext: aie -, acral WDR

    Clinical photo

    Clue and Cue

    male, 44 yo
    GCS 356
    vulnus app et regio supra orbita dextra panjang 5 cm
    heacting, hematome palperbra D et S, vulnus
    apperteum nasal 2x1 cm, krepitasi nasal (+), epitaxis
    (+) edema maxila D et S, floating maxila (+), fals
    movement (+)
    vomiting

    Clinical Assesment
    Mild brain injury
    Fracture maxila
    Fracture nasal

    PLANING DIAGNOSIS
    Thorax x-ray
    CT SCAN
    DL

    Laboratorium
    Hematologi
    Hematokrit : 4.59(L 40-54%, P 35-47%)

    MPV : 4 fl (5-10)

    Hemoglobin
    L13-18 mg/dl)

    MCV : 85.10 fl (87.00-100.000)

    : 13.0 mg/dl (P12-16 mg/dl,

    MCH

    : 27.7 pg (28.00-36.00)

    Leukosit

    : 12.2 / uL (4000-11.000)

    MCHC : 32.60 g/dL(31.00-37.00)

    Trombosit

    : 176 /uL (150.000-450.000)

    RDW

    Neutropil

    : 77.3 % ( 49.0-67.0)

    GDA : 120

    Limfosit

    : 15.1 % (25.0-33.0)

    HbsAG negatif

    Monosit

    : 5.1 % (3.0-7.0)

    Eosinofil

    : 0.3 % (1.0-2.0)

    Basofil
    Eritrosit

    : 2.2 % (0.0-1.0)
    : 3.83 / uL(3.800.000-5.300.000)

    : 12 % (10-16.5)

    Planning Therapy
    O2 NRM 10 lpm
    Inf. Loading asering 1000cc maintenence
    1500cc/24jam
    Inj. Matamizole 3x1 gr iv
    Inj. Pantoprazole 2x40mg iv
    Inj. Ceftriaxon 2x1 gr iv
    Inj. Piracetam 4x3 gr iv
    inj. Asam traknesamat 3x500 mg iv
    Consult Sp.BKL

    Monitoring

    Complaint
    Vital sign

    Education
    Explaine to the family about the disease, about its
    therapy and intervention will be done, and also about
    complication and prognosis.

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