MORNING REPORT SURGERY DEPARTMENT DM E-17

15th

February 2013

Patients Identity
Name : Mr. S Age : 55 year Sex : man ID : 082597 Religion : moslem Address : Lamongan

Summary of Database
Chief complaint : right ear pain Present illness history: Patient complained pain in right ear after got traffic accident. The accident happened for about 15 minutes before hospitalized. When the accident happened, patient was driving becak. A motor driver crashing his becak suddenly from his behind side. Then patient fallen down to the right side of his body. He remembered the accident exactly. He felt headache. Nausea (-). Vomit (-). His right ear was bleeding.

Patients Status
Vital signs General appearence, awareness, GCS Weak , CM, 456

Blood Pressure
Pulse Rate Temperature Respiratory Rate

141/97 mmHg
76x/mnt 36,1 C 20X/mnt

Primary Survey
Airway + control servical - airway clear (+), snoring (-), gargling (-) Breathing - simetric (+), ves/ves, rh -/-, wh -/-, RR 20 x/minutes Circulation - acral: dry and warm to touch - pulse rate: 76 x/m - heart rate: 141/97 mmhg

 Disability - GCS 456 - light perception +/+ - Pupil isocor 3mm/3mm - lateralisation (-) Exposure - temperature 36,1 C - bloody otorea in auricularis dextra (+) - bloody rhinorea (-), battle sign (-), racoon eyes (-)

Secondary survey
Head : An -/- ; Ict -/- ; Cya -/- ; Dysp Thorax
Symmetric -, retraction Pulmo : RR: 20x/m, Ves/ves, Rh-/-, Whz-/ Cor : HR: 76x/m, reg (+) S1S2 tunggal, M-

 Abdomen
Inspection Palpation Auscultation Percution : flat : soefl, pain (-) in all quadran abdomen, H/L just palpable : Bowel sound (+) N : met (-)

Extremity : acral warm and dry

LABORATORY FINDING
Diffcount Hct Hb Leukosit Trombosit : 11/3/35/31/19 : 38,8 % : 13.0 mg/dl : 7.100 : 233.000

Clue and cue

Man , 55 years Post traffic accident PTA (-) Headache Nausea (-) Vomit (-) Bloody otorea +/Battle sign -/Bloody rhinorea -/Racoon eyes -/-

Problem List
Post traffic accident PTA (-) Headache (+) Bloody otorea +/-

Initial Diagnose
Mild head injury

Planning of diagnose
CT Scan

Planning of therapy
O2 NC 3 lpm IVFD Asering 1500 cc/ 24 hour Inj. Ketorolac 3x30 mg Inj. Ranitidin 2x50 mg Inj. Piracetam 4x1 gr Inj. Ceftriaxon 2x1 g

Monitoring
Vital signs Patients complain

Prognosis
Dubia ad bonam