morning report 3rd aprl 2014
TRANSCRIPT
Morning report 3rd Aprl 2014
Konsulen dr. Jean Pello, SpB
DM Desendio KTPDM Isni Ardhia
1ST CASE
BIODATA
• Name : Ms. As• Age : 18 years old• Sex : FeMale• Address : Naikoten• Job: College
Anamnesis
• Chief Complaint : pain and laceration on ankle
• MOIpatient come to ER because of pain and laceration on angkle. Laceration caused by dog bite 4 hour before admitted to the ER. She was bitten by her neighbor dog which it in maternal phase. The dog bit on behind foot and make some laceration wounds, pain, and bleeding. Nause-vomit, fever, dizziness, malaise doesn’t present. patient poured the wound with coffee in order to stop the bleeding.
Primary Survey
• A: Patent, clear• B : RR: 20 times/min, spontan• C : Blood pressure : 120/70 mmHg , Pulse: 92
times/minute, reguler. • D : GCS E4V5M6• E :Multiple V. Laceration on region maleolus
lateralis and medialis (0,2x1 cm), bleeding (-)
Secondary Survey
• GCS : E4 V5 M6• Head : Normal• eyes : anemic (-/-), light reflex (+/+), icteric (-/-)
, isokhor +/+• Ear : normal• Nose : normal• Neck: Normal
Thorax
• Inspection : chest expansion simetrics, reguler, abdominothoracal, Bruish (-)
• Palpation : vocal fremitus R=D, krepitasi (-), Pain (-)
• Percusion: sonor (+/+)• Auscultation : vesicular (+/+), ronchi (-/-),
wheezing (-/-)
Abdomen
• Inspection : look flat, follow the chest expansion
• Palpation : pain (-), mass (-), tenderness (-)• Percusion : timpany (+)• Auscultation : peristaltics (+), normal
Extremity
– Look
Multiple V. Laceration on region maleolus lateralis and medialis (0,2x1 cm), bleeding (-)
– Feelpain (+)
– Move• ROM : normal
Assessment
• Vulnus Morsum e.c Dog bite
Planning therapy
• Wound toilet• Anti tetanus serum• Mefenamat Acid 3x1 tab• Amoxicillin 3x1 tab
• Picture
2ND CASES
BIODATA
• Name : Mr. RF• Age : 68 years old• Sex : Male• Address : Rote Ndao• Job: Farmer
Anamnesis
• Chief Complaint : Difficult urinate
• MOIpatient has difficult to urinate for the last 3 month,he also complain that he must strain his abdominal muscle when getting the urinate. But he felt his urine still left behind on the abdomen so make him doesn’t satisfy, his other complain: not adecuat in urinate flow, pain after urinate, increase the urinate frequency, 5 time/days especially in the night. In this patient doesn’t present fever, nausea- vommit, dyspnea, abdominal pain and he has normal in urinate consistency
Secondary Survey
• GCS : E4 V5 M6• Head : Normal• eyes : anemic (-/-), light reflex (+/+), icteric (-/-)
, isokhor +/+• Ear : normal• Nose : normal• Neck: Normal
Thorax
• Inspection : chest expansion simetrics, reguler, abdominothoracal, Bruish (-)
• Palpation : vocal fremitus R=D, krepitasi (-), Pain (-)
• Percusion: sonor (+/+)• Auscultation : vesicular (+/+), ronchi (-/-),
wheezing (-/-)
Abdomen
• Inspection : look flat, follow the chest expansion
• Palpation : pain (-), mass (-), tenderness (-)• Percusion : timpany (+)• Auscultation : peristaltics (+), normal
Extremity
warm, CRT<2”, Edema (-/-,-/-)
STATUS UROLOGIS• Regio Flank D / S– Inspection: Skin color normal, inflammation sign (-),
hematoma (-), vertebra alignment normal, gibbus (-), mass (-).
– Palpation: Ballottement (-/-)– Percusion: CVA pain(-/-)
• Regio Suprapubic– Inspection: Skin color normal, inflammation sign (-),
hematoma (-)– Palpation: Bladder full, pain (+),
• Regio Genitalia Exsterna
– Penis• Inspection: Skin color normal,
inflammation sign (-), hematoma (-), oedema (-)
– Scrotum• Inspection: Skin color normal,
inflammation sign (-), hematoma (-), oedema (-)
• Palpation: Testis 2 pairs, size normal, pain (-)
Rectal Toucher:• Anus and perineum normal• Tonus spincter ani eksterna normal•Ampula recti: dilatation, mucosa slippery, flat, surface flat, consistency rubbery, pain (-), nodul (-),•Sulcus medianus flat, can’t reach upper lobe•Handscone : mucous (-), blood (-), stool (+)
Assessment
• RETENSIO Urine e.c BPH dd Stone in urinary tract
Planning therapy
• DC• Drink 1600 cc/days
• Picture