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Morning Report

• Name : Child Erwin erlangga


• Age : 13 Years old
• Sex : Male
• Address : Pamandati
• Admission : July, 10th, 2018
• Doctor in charge : dr. Syamsul Rijal, Sp.B
• Main Complain : Uncounsiusness
• Anamnesis :
Suffered since 2 hours ago after Traffic Accident.
• MOT
Patient riding a motorcycle with high speed, not using
HISTORY helmet. His motorcycle crushed with a car. Mechanism of
trauma is unknown.
TAKING  History of unconciousness (+) nausea (-), vomiting (-)
 Bleeding from ear (-), bleeding from nose (), bleeding
from mouth (-)
 History of consumption alcohol (-) drugs (-)
 History of previous medication (-)
A Clear, O2 Via canul nasal 3lpm

B Respiratory rate 22x/m,


spontaneous

PRIMARY
SURVEY C Blood Pressure 150/90 mmHg
Pulse 64x/m, ireguler, strong

Glasgow Coma Scale 5


D (E1M3V1), Isochoric pupil, Ø 1
mm/1 mm, Light reflex +/+

E Temperature 36,8OC/Axillary
Ears : Normally
Neck : Normally
Head : Normally
GENERALIZED Face : Localized
Chest : Normally
STATUS Eyes : Normally Extremity
Nose : Normally Superior :
Mouth : Normally Normally
Inferior :
Normally
FACIALIS REGION
Inspection
Deformity (-), Sweeling (+), Hematom (+), wound (+)
vulnus excoriatum at frontalis region 3 x 1 cm
LOCALIZED vulnus excoriatum at temporalis region 2 x 1 cm

STATE vulnus excoriatum at zygomaticum region 2,5 x 2,5 cm

Palpation
Tenderness (+)
CLINICAL
DOCUMENTATION
routine
Blood
PLAN OF
DIAGNOSTIC

CT-Scan
LABORATORIUM FINDING
Routine Blood 10-7-2018

Parameter result Unit Reference value

WBC 19,96 10^3/uL 4.00-10.00

HGB 12,8 g/dL 12-16

PLT 298 10^3/uL 150-400


Skull CT Scan
SEVERE HEAD
DIAGNOSE INJURY GCS 3
IVFD

Neuroprot Urine
ector catheter
CONSULT
MANAGEMENT GENERAL
SURGEON

H2RA Antibiotic

Analgetic