Scribd Logo
Upload

Welcome to Scribd!

  • 30 views

    Morning Report: Fakultas Kedokteran Universitas Muhammadiyah Malang Rumah Sakit Muhammadiyah Lamongan 2016

    Uploaded by

    Inassani Alifia
    A 60-year-old male farmer was referred to the hospital after a traffic accident where he was hit from behind by a motorbike while riding his bicycle. He sustained a head injury which was sutured at a local clinic. At the hospital, he was found to have a hematoma on the left side of his forehead near the suture site with a Glasgow Coma Scale of 15/15. Laboratory results and physical exam were otherwise normal. He was diagnosed with a mild head injury and suspected frontal bone fracture. Treatment included intravenous fluids, antibiotics, analgesics and medications to prevent increased intracranial pressure with plans for a CT scan if pressure increased.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Morning Report: Fakultas Kedokteran Universitas Muhammadiyah Malang Rumah Sakit Muhammadiyah Lamongan 2016

    Uploaded by

    Inassani Alifia
    30 views10 pages
    A 60-year-old male farmer was referred to the hospital after a traffic accident where he was hit from behind by a motorbike while riding his bicycle. He sustained a head injury which was sutured at a local clinic. At the hospital, he was found to have a hematoma on the left side of his forehead near the suture site with a Glasgow Coma Scale of 15/15. Laboratory results and physical exam were otherwise normal. He was diagnosed with a mild head injury and suspected frontal bone fracture. Treatment included intravenous fluids, antibiotics, analgesics and medications to prevent increased intracranial pressure with plans for a CT scan if pressure increased.

    Original Description:

    morning report bs

    Original Title

    Morep Ckr Inas

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    A 60-year-old male farmer was referred to the hospital after a traffic accident where he was hit from behind by a motorbike while riding his bicycle. He sustained a head injury which was sutured at a local clinic. At the hospital, he was found to have a hematoma on the left side of his forehead near the suture site with a Glasgow Coma Scale of 15/15. Laboratory results and physical exam were otherwise normal. He was diagnosed with a mild head injury and suspected frontal bone fracture. Treatment included intravenous fluids, antibiotics, analgesics and medications to prevent increased intracranial pressure with plans for a CT scan if pressure increased.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    30 views10 pages

    Morning Report: Fakultas Kedokteran Universitas Muhammadiyah Malang Rumah Sakit Muhammadiyah Lamongan 2016

    Uploaded by

    Inassani Alifia
    A 60-year-old male farmer was referred to the hospital after a traffic accident where he was hit from behind by a motorbike while riding his bicycle. He sustained a head injury which was sutured at a local clinic. At the hospital, he was found to have a hematoma on the left side of his forehead near the suture site with a Glasgow Coma Scale of 15/15. Laboratory results and physical exam were otherwise normal. He was diagnosed with a mild head injury and suspected frontal bone fracture. Treatment included intravenous fluids, antibiotics, analgesics and medications to prevent increased intracranial pressure with plans for a CT scan if pressure increased.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    You are on page 1of 10

    Morning Report

    Dept. of Surgery
    J-23
    FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH
    MALANG
    RUMAH SAKIT MUHAMMADIYAH LAMONGAN

    Patient Identity

    Name
    : Mr. D
    Age : 60 y.o
    Address
    : Lamongan
    Occupation : Farmer
    Marriage status: Married

    Present History
    Patient reffered from Sekaran Clinic post traffic
    accident this evening. Patient was wanted to go
    to the field by bicycle, then from backward
    there was a motorbike crush him, then patient
    fall down but he dont remember how he falls
    down. Then patient carried to Sekaran clinic
    and his front head and forth right finger was
    sewn. A few minutes later patient was
    vomitting with blood. Dyspnoe (-), Now patient
    feel dizzy and headache.

    Physical Examination
    Vital sign:
    TD: 114/60 mHg
    N: 73 xm
    RR: 20x/m
    T: 35.4C
    SpO2: 100% without O2 support
    GCS 356
    Primary Survey:
    A : Gargling (-) snoring (-) pot. Obstruction (+)
    B : Spontan, RR 22x/m, ves|ves, rh -|-, wh -|C : Extremity WRD, CRT <2, N 73x/m, TD 114/60
    D: GCS 356, lateralisasi (-) pupil isocor 3mm|3mm
    LP +|+

    Physical Examination
    Secondary Survey:
    Head and neck: a-/- i -/- c -/- d
    Brill hematome Sinistra (+), vulnus
    apertum frontal head sinistra
    sewn. otorheae (-) rhinroheae (-)
    lesion retro aurikula (-)Lesion
    supraclavicula (-)
    Thorax:
    Inspection: Simetris, retraction (-|-)
    cor: s1 s2 single reg, m (-), g (-)
    pulmo: sonor|sonor, ves|ve, rh -|-,
    wh -|Abdomen:
    Flat, soefl, lesion (-), tympani, bowel
    sound (+) wnl
    Extremity:
    Regio manus D vulnus apertum sewn

    Laboratory findings

    GDA 161
    BUN 27/ SC 0.6
    OT 44/ PT 24
    Leu 8.7
    Neu 81.5
    Lymph 7.5
    Mono 6 | Bas 1
    Eri 3.5
    Hct 32.3
    Hb 10.8
    Plt 207

    Thorax Ro

    Clue and cue


    Headache
    Post traffic accident
    Brill hematome Sinistra (+), vulnus
    apertum frontal head sinistra sewn.
    otorheae (-) rhinroheae (-) lesion retro
    aurikula (-)Lesion supraclavicula (-)

    Clue and cue


    Headache
    Post traffic accident
    Brill hematome Sinistra (+), vulnus
    apertum frontal head sinistra sewn.
    otorheae (-) rhinroheae (-) lesion retro
    aurikula (-)Lesion supraclavicula (-)
    GCS 356
    Problem list
    Mild Head Injury
    dd susp. Fr. Basis cranii

    Therapy

    Inf. RL 1500cc/24 j
    Inj. Ceftriaxone 2x1 gr iv
    Inj. Ranitidine 2x50 mg iv
    Inj. Ceteron 3x8 mg iv
    Inj. Piracetam 4x 3 gr iv
    Inj. Citikolin 3x250 mg iv
    Pro CT scan if ICP increase

    You might also like